Help w/ care plan (concept map)
- 0Nov 2, '08 by avahnelI am having a hard time coming up w/three nursing dx, goals ect. for concept map.
Assessment: 85 yo F resident of a LTC admitted with cellulitis unresoved with oral antibiotics. Admitted for IV vancomycin. Renal imparment; only getting antibiotic every other day. Bilat LE deep purple, hot and tender to touch, +1 edema. A/O x1 not to time or place (knows she is not where she lives but not that she is in the hospital). Only other history I have is that she has organic dementia. She is a poor historian. No pain stated when asked, but does guard her legs. Speach clear, moves all extremities with equal strengh (very weak). Apical HR regular 67. Lungs clear. Abd soft, non tender bowel sounda present in all 4 quads. Has a foley, clear yellow urine, adequate output. Erythematous lesion under L breast (poss yeast infection) barrier cream applied. RN will ask Dr if nystatin powder in indicated. Pt has patent hep lock in L AC. She is a fall risk.
We do consept maps. We have to give top 3 dxs, goal for each and 5 interventions that can be done. Here is what I have so far. Help would be appreciated!!! :-)
PMH: Dementia, renal insufiency
Priority Assessments: VS, Skin, Mental Status, Urine output.
1. Impaired Tissue Integrity R/T (dont know) AEB bilat LE hot, tender to touch, + 1 edema, local pain.
Goal. Bilat LE tissue improves AEF decreased redness, swelling and pain.
Antibiotics as ordered
Encourage adequate nutrition
2. Self Care Deficit R/T organic dementia AEB inability to toilet, transfer, bathe and groom self.
Goal: pt safely performs grooming tasks (to maximum ability)
Use consistant routines and allow adequate time for tasks
Set short term goals.
3. Impaired Mobility R/T limited strength AEB Limited ROM, Decreased muscle endurence, strength
Goal Pt performs physical activity with assistive devices
Turn and reposition every 1 1/2 to 2 hours.
passive and active ROM excersises.
Thanks for any input!!!
- 15,260 Visits
- 1Nov 2, '08 by Daytonitei took all the data you posted and organized it by medical diagnosis, doctor's treatment orders and then the assessment data you collected.
- 85 year old female
- cellulitis bilateral lower extremities
- organic dementia
- renal impairment
- erythematous lesion under l breast (poss yeast infection)
- medical treatment
- iv vancomycin
- has a foley catheter
- hep lock in l ac
Last edit by Daytonite on Nov 3, '08
- +1 edema
- legs deep purple color
- legs hot and tender to touch
- ineffective tissue perfusion, peripheral r/t impaired circulation aeb +1 edema of lower extremities, deep purple coloration and legs hot to touch
- limited rom - should be more specific in description
- decreased muscle endurance and strength - should be more specific in description
- weak movements of legs
- impaired physical mobility r/t deconditioning and cognitive impairment aeb weak movements of legs, limited rom, decreased endurance and strength and disorientation
- guards her legs/legs tender to touch
- acute pain r/t inflammation in tissues aeb legs tender to touch and guarding of legs
- inability to toilet, transfer, bathe and groom self
- (bathing/hygiene, dressing/grooming. feeding) self-care deficit
- erythematous lesion under l breast
- impaired skin integrity
- a/o x1 to person
- chronic confusion
- fall risk
- 85 years old
- risk for falls