Help w/ care plan (concept map)

  1. I 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.

    Vitals 0800
    T 98.5
    P 72
    R 18
    BP 134/66

    T 98.3
    P 67
    R 16
    BP 127/64

    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!!! :-)

    Dx: Cellulitis
    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.
    Positive reinforcement.

    3. Impaired Mobility R/T limited strength AEB Limited ROM, Decreased muscle endurence, strength

    Goal Pt performs physical activity with assistive devices

    Encourage ambulation
    Turn and reposition every 1 1/2 to 2 hours.
    passive and active ROM excersises.

    Thanks for any input!!!
  2. Visit avahnel profile page

    About avahnel

    Joined: May '08; Posts: 173; Likes: 73
    Correctional Nurse; from US
    Specialty: 5 year(s) of experience in Orthopedic, Corrections


  3. by   Daytonite
    i 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
    determination of the patient's problem(s)/nursing diagnosis - make a list of the abnormal assessment data – match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use - the data is grouped and reorganized by maslow's hierarchy of needs. they are matched to appropriate diagnoses.
    • +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
    nursing interventions target the abnormal data that supports (is the evidence) of each problem. a goal is always going to be the predicted results of your interventions.
    Last edit by Daytonite on Nov 3, '08
  4. by   avahnel