Concept Map for Cellulitis of Right Forearm

NightNurseRN13 · Nov 4, 2011

I've added the following since my last post

interrupted family processes r/t situation transition AEB: "My wife will have to watch the kids" "My kids will probably worry about me", patient is in the hospital, pt. is worried about returning to work

Excess fluid volume r/t complex factors AEB: Anxiety, Edema, Intake exceeds output

Disturbed body image r/t injury AEB: I hope I get over this infection. I need all the strength in my arms for work" (verbalization of feelings that reflect altered view of function), present wound

If I can come up with one more, I'll have all 11 boxes filled!!

xtxrn, ASN, RN · Nov 4, 2011

i've added the following since my last post
interrupted family processes r/t situation transition aeb: "my wife will have to watch the kids" "my kids will probably worry about me", patient is in the hospital, pt. is worried about returning to work
excess fluid volume r/t complex factors aeb: anxiety, edema, intake exceeds output
disturbed body image r/t injury aeb: i hope i get over this infection. i need all the strength in my arms for work" (verbalization of feelings that reflect altered view of function), present wound
if i can come up with one more, i'll have all 11 boxes filled!!

i'm not following how anxiety is r/t excess fluid volume. also, if the edema is localized at the infection site (and not observed anywhere else) i would see it as more of a result of the infection- not a generalized issue like excess fluid volume; if i>o, i could see monitoring and a "potential" fluid volume excess.

let me look at the first post :)

xtxrn, ASN, RN · Nov 4, 2011

i have a head to toe assessment simulation coming up and we have to do a concept map on our patient. normally we would need to fill all 11 boxes and normally i don't have any issues doing this (when it's a real patient with multiple problems), but the only thing my fake patient has is cellulitis.
here's more about "him"
vital signs stable; low-grade fever. alert and oriented. redness and swelling present in 12 x 15-cm area immediately surrounding 3-mm circular wound on right inner aspect of forearm. patient guarding forearm; rates pain as 3/10 and describes it as "tender." no other complaints.
patient presented to the emergency department at 0845 with complaints of redness, discomfort, and mild swelling of right forearm and low-grade fever. reports sustaining puncture wound of right inner forearm last friday while working with dirty equipment at construction job site. puncture wound measures 3 mm in diameter; skin intact. erythema measures 12 x 15 cm immediately around puncture site. patient denies chronic skin conditions, underlying illness, recent travel, recreational drug use, previous infection at same site, and other environmental exposure. denies loss of function; reports mild pain and tenderness with palpation and movement of right forearm. no crepitus with palpation of site. no bullae present. pain is in proportion to the soft-tissue involvement. likely uncomplicated cellulitis; however, cannot rule out complicated necrotizing infection or methicillin-resistant staphylococcus aureus. currently blood pressure is stable; patient does not appear septic. will obtain blood cultures and labs. admit for iv antibiotics. wound closed, so wound cannot be cultured. no known allergies. full code.
here's what i have so far:
ineffective health maintenance r/t lack of prevention of further incidences of infection aeb: pt. performed no cleaning of wound, pt. waited 3 days before seeking care, pt. working with dirty equipment, present infection
fear r/t change in health status aeb: subjective data: "i hope i get over this infection. i need all the strength in my arm for work" and "i hope my boss doesn't get mad that i'm missing work"
impaired tissue integrity r/t complex factors aeb: inflammatory process damaging skin and underlying tissues, iv access, present infection, closed wound, warmth and redness of right forearm "closed wound" is a bit weak; maybe just leave the rest?
risk for vascular trauma: infusion of antibiotics (nafcillin)
risk for infection: current present infection, iv access, elevated wbcs, in the hospital, wound, tender and palpable axilla lymph nodes, present fever the actual infection needs to be addressed separately since it's the reason for admission
acute pain r/t inflammatory changes in tissues from infection aeb: edema in right forearm (slight 1+), pt. reported pain of 3 on a scale of 1-10
ineffective peripheral tissue perfusion r/t edema aeb: warmth and redness of skin on right forearm, slight 1+ edema present on right forearm is the edema really pitting to 1+? (most wounds are more likely to be firm); edema does not have to be pitting; sometimes it's generalized or localized.
and now i'm just stuck, i can't think of anything else. does what i have look okay?
p.s. i am a first semester nursing student

also, how are you going to prioritize these? :)

you're doing a good job with coming up with the problems, and your reasoning :up:

is there anything r/t any possible booster immunizations w/the dirty tool??? where would you include anything like that?

NightNurseRN13 · Nov 5, 2011

Right now we are just working on our #1 and #2 and what interventions we would establish.

For this patient I was say ineffective health maintenance and risk for infection were my top priorities.

Client education would be a huge focus and then monitoring lab results and temperature would def. be part of my assessment/evaluation.

Tetorifice shot and the last time administered and if it's due would be a biggy

Esme12, ASN, BSN, RN · Nov 5, 2011

here are the steps of the nursing process and what you should be doing in each step when you are doing a written care plan:

assessment (collect data from medical record, do a physical assessment of the patient, assess adl's, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology)
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)
planning (write measurable goals/outcomes and nursing interventions)
implementation (initiate the care plan)
evaluation (determine if goals/outcomes have been met)

now, listen up, because what i am telling you next is very important information and is probably going to change your whole attitude about care plans and the nursing process. . .a care plan is nothing more than the written documentation of the nursing process you use to solve one or more of a patient's nursing problems. the nursing process itself is a problem solving method that was extrapolated from the scientific method used by the various science disciplines in proving or disproving theories. one of the main goals every nursing school wants its rns to learn by graduation is how to use the nursing process to solve patient problems

http://www.snjourney.com/clinicalinfo/careplans/conceptmapguide.pdf

http://nah.southtexascollege.edu/adn/assets/docs/shartle/clinical%20concept%20map%20sample%20format%20rnsg%201162%20revised.pdf a general concept map made up to follow through.

http://www.pterrywave.com/nursing/care%20plans/nursing%20care%20plans%20toc.aspx

http://www.csufresno.edu/nursingstudents/fsnc/nursingcareplans.htm

http://www.snjourney.com/clinicalinfo/careplans/careplann.htm

NightNurseRN13 · Nov 5, 2011

Thank you Esme12, I will def. use the resources you posted in the future. I understand the Nursing Process is a HUGE concept that we need to understand fully. I believe the reason I was having issues with this "patient" was because there wasn't much information on him and I never got to meet him because he was hypothetical.

After simulation though, I had a greater understanding of the patient's condition and added things to my concept map.

A care plan wasn't required for this "patient", so I didn't include any interventions in my original posts.

nurseprnRN, BSN, RN · Nov 6, 2011

i'd like to give a few extra kudos to esme for her comprehensive explanation, and to the op for doing a helluva good job as a first attempt. :yeah: :yeah: :yeah:

might i ask what references you used and how your faculty got you so well-prepared to think this clearly so early in your education? :nurse: it would be great if other faculties could go and do likewise, judging from the mass confusion we so often see in first-year students this time of year.

not sure about "risk for infection," as it seems this fella already has one, unless you're thinking tetorifice. agree with the advice on prioritizing. there may be no exactly right answer after you get past the first few real life-and-limb ones, but that gives you a chance to defend your reasoning. it's all good. :yeah:

NightNurseRN13 · Nov 6, 2011

i'd like to give a few extra kudos to esme for her comprehensive explanation, and to the op for doing a helluva good job as a first attempt. :yeah:

might i ask what references you used and how your faculty got you so well-prepared to think this clearly so early in your education? it would be great if other faculties could go and do likewise, judging from the mass confusion we so often see in first-year students this time of year.

not sure about "risk for infection," as it seems this fella already has one, unless you're thinking tetorifice. agree with the advice on prioritizing. there may be no exactly right answer after you get past the first few real life-and-limb ones, but that gives you a chance to defend your reasoning. it's all good.

thank you so much!!

i used my nursing diagnosis handbook, taber's cyclopedic medical dictonary (they have a bunch of nursing diagnoses in the back), my med/surg book to research cellulitis and also the library's databases for scholary articles about cellulitis.

i'm not sure what the faculty has done differently than other faculty as we all feel like we are struggling week to week when it comes to these concept maps.

NightNurseRN13 · Nov 7, 2011

I'm not following how anxiety is r/t excess fluid volume. Also, if the edema is localized at the infection site (and not observed anywhere else) I would see it as more of a result of the infection- not a generalized issue like excess fluid volume; if I>O, I could see monitoring and a "potential" fluid volume excess.
Let me look at the first post :)

I wasn't sure how anxiety related to fluid retention either, so I looked it up and it is related to the adrenal glands

"These glands control many functions from anti-inflammatory (ridding the body of pain and swelling) and immune system protection to balancing fluid and salt levels and controlling minerals (such as potassium), rapid heart rate, regulating blood pressure, and sleep and awake cycles."

nurseprnRN, BSN, RN · Nov 7, 2011

just because the adrenals help regulate na+/h2o and get involved when you're anxious doesn't mean that if you're anxious you'll become edematous. :)

i hope other students take note of your resources and go get them too. sounds like they're working pretty well for ya :yeah:

Esme12, ASN, BSN, RN · Nov 7, 2011

i wasn't sure how anxiety related to fluid retention either, so i looked it up and it is related to the adrenal glands
"these glands control many functions from anti-inflammatory (ridding the body of pain and swelling) and immune system protection to balancing fluid and salt levels and controlling minerals (such as potassium), rapid heart rate, regulating blood pressure, and sleep and awake cycles."

possible but the anxiety/stress would have to be extreme as in a heart problem called "broken heart syndrome" or takotsubo cardiomyopathy, also known as transient apical ballooning syndrome, apical ballooning cardiomyopathy, stress-induced cardiomyopathy, gebrochenes-herz-syndrom, and simply stress cardiomyopathy, is a type of non-ischemic cardiomyopathy in which there is a sudden temporary weakening of the myocardium (the muscle of the heart). because this weakening can be triggered by emotional stress, such as the death of a loved one, a break-up, or constant anxiety. stress cardiomyopathy is a well-recognized cause of acute heart failure, lethal ventricular arrhythmias, and ventricular rupture.

i would assume the swelling would be from the inflammatory process of the infection itself or they have not been truthful about iv drug use. cellulitis is a diffuse inflammation of connective tissue with severe inflammation of dermal and subcutaneous layers of the skin. cellulitis can be caused by normal skin flora or by exogenous bacteria, and often occurs where the skin has previously been broken: cracks in the skin, cuts, blisters, burns, insect bites, surgical wounds, intravenous drug injection. skin on the face or lower legs is most commonly affected by this infection, though cellulitis can occur on any part of the body. erysipelas is the term used for a more superficial infection of the dermis and upper subcutaneous layer that presents clinically with a well-defined edge. erysipelas and cellulitis often coexist, so it is often difficult to make a distinction between the two.

cellulitis is caused by a type of bacteria entering the skin, usually by way of a cut, abrasion, or break in the skin. this break does not need to be visible. group a streptococcus and staphylococcus (mrsa) are the most common of these bacteria, which are part of the normal flora of the skin, but normally cause no actual infection while on the skin's outer surface.

predisposing conditions for cellulitis include insect or spider bite, blistering, animal bite, tattoos, pruritic (itchy) skin rash, dry skin, eczema, injecting drugs (especially subcutaneous or intramuscular injection or where an attempted intravenous injection "misses" or blows the vein), pregnancy, diabetes and obesity, which can affect circulation, as well as burns and boils, though there is debate as to whether minor foot lesions contribute.

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this reddened skin or rash may signal a deeper, more serious infection of the inner layers of skin. once below the skin, the bacteria can spread rapidly, entering the lymph nodes and the bloodstream and spreading throughout the body. this can result in influenza-like symptoms with a high temperature and sweating or feeling very cold with shaking, as the sufferer cannot get warm.

in rare cases, the infection can spread to the deep layer of tissue called the fascial lining. necrotizing fasciitis, also called by the media "flesh-eating bacteria", is an example of a deep-layer infection. it is a medical emergency.