i need one more diagnosis. i struggled with the first one.
ineffective peripheral tissue perfusion r/t tissue inflammation s/t cellulitis aeb pt stated tenderness in right lower leg, redness and warm to touch.
pt right lower leg will show signs of healing during my shift within 12 hours (decrease appearance of redness, swelling and pain in affected areas).
collaborate with the woc nurse for wound care plan.
nurse will elevate the pt's lower extremities on pillows above the heart level to decrease swelling.
reposition pt every 2 hours. offer pain medication at least 20 minutes before position change.
teach pt importance of proper nutrition in wound healing.
this is what was provided:
history and physical
date of admission: 2 days ago
attending physician: dr. pearla
chief complaint: chest pain
history of present illness and reason for admission
this is an 80 yr old white female that was brought to er by paramedics. while at a family dinner she c/o chest pain, shortness of breath, weakness and dizziness. paramedics were called, ekg indicated possible acute mi. oxygen and nitro were given and pt. was transferred to the hospital.
she was also noted to have an open wound on her right lower leg, per patient it occurred last week when she fell in her bathroom. wound with purulent drainage and redness.
on routine tests pt. was found to be dehydrated. her blood sugar was elevated at 400 and also was diagnosed with cellulitis of right lower leg due to staph infection and was started on iv rocephin. iv fluids and insulin drip were started.
she was admitted to ccu.
past medical history:
1- diabetes type ii
3- coronary artery disease
4- frequent utis
1- appendectomy - 1956
social history: pt. is widowed, lives alone in a senior housing community. occasional smoker 1-2 per week. no alcohol. she has 2 daughters living in the area, both work full time. she admits to being non-compliant with her diet and forgetful with medications at times.
well developed obese elderly female, alert and oriented. vital signs: t= 100, p=90, r =20, bp= 150/88. pulse ox=95, weight= 190lbs, height= 5'2''. c/o 5/10 pain in her right lower leg. neck is supple, no jugular venous distention, no carotid bruit, no thyromegally. multiple bruises noted on the arms. right lower leg with an open wound with yellow discharge, area red, warm and tender to touch. lungs are clear to auscultation bilaterally, heart sounds indicates a murmur, rate at 90, regular rhythm; abdomen is soft with tenderness at suprapubic region with left cvat.
1- urine culture showed pseudomonas aeruginosa sensitive to gentamacin.
2- tissue culture showed staph aureus sensitive to amoxicillin so rocephin was discontinued and amoxicillin and gentamacin were started.
3- ekg with sinus tachycardia
4- bed side blood sugars were decreased to 120-130, so insulin drip was discontinued and placed on lantus insulin 20 units at bedtime and humalog 5-10 units pre-meals per sliding scale.
5- cbc- wbc: 13.5 ( 3.8-10.8) , hgb: 12.5 (11.7-15.5) , hct: 40.0 (35.0-45.0), platelates 284 ( 140-400)
6- bmp- glucose 160 (60-99) , bun 28 ( 7-25), creatinine 1.0 ( 0.60-1.18), gfr 45 ( >60), na 160 (135-146), k 4.9 ( 3.5-5.3), hga1c 11 ( <5.7)
1- htn-poorly controlled
2- s/p mi
3- dm ii- poorly controlled
4- cellulitis right lower leg
1- iv fluids
2- iv antibiotics
3- daily wound care
4- dietary evaluation- diabetic diet and nutrition education and weight loss
5- continue with current meds.
6- cardiac monitoring
7- cardiac rehab.
1- aspirin 81mg 1 tab po daily
2- lantus insulin 20 units qhs
3- humalog insulin 5-10 units ac meals per sliding scale
4- atenolol 50 mg po bid
5- gentamycin 1gm iv q12 hrs
6- amoxicillin 500mg iv q8 hrs
7- lisinopril 20 mg po daily
8- metformin 500mg po bid