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
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
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
and now I'm just stuck, I can't think of anything else. Does what I have look okay?
Thank you for your post Esme!! Very glad to have you on this forum! :) It is comforting to know that I have a place to go to for advice and information. :)
Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
Thank you for your post Esme!! Very glad to have you on this forum! :) It is comforting to know that I have a place to go to for advice and information. :)
YOU did the leg work and showed you had done thinking, effort and research.
NightNurseRN13
353 Posts
Thank you for your post Esme!! Very glad to have you on this forum! :) It is comforting to know that I have a place to go to for advice and information. :)