Hi there guys! I am new here! I am a 2nd semester student and today I had a very complicated patient and to top it all of, I lost most of my patient's information (eek). So I am trying to do my best on my care plan from what I remember and the notes I was able to salvage. I am hoping for a little bit of advice or confirmation that I am on the right track with my care plan, I greatly appreciate it. This is my patient's information:
65 yo Hispanic male, hx chronic left diabetic foot ulcers, DM 2, dyslipidemia, HTN, CHF with EF 25-35% (N >55%, echo done 2/14/14), hx MI, peripheral neuropathy, CKD, aortic atherosclerosis. Pt has been non compliant with post-op shoe, and blood sugar monitoring. Left foot ulcers were debrided 5/28/14, given Keflex, debridements on 6/20/14, 7/10/14, 7/31/14. Pt developed blisters on top of left foot and saw podiatrist again on 9/24/14, debrided again and gave rocephin x1 and Keflex. patient returned on 9/29 for CC worsening symptoms, signs of infection; drainage, odor, cellulitis of ankle and leg. Sent to ED for admission and IV antibiotics, XR did not reveal osteomyelitis. I&D on 9/30/14. 10/2 angiogram s/p angioplasty by vascular, 10/3 debridement of left foot, 10/4 no changes, plan for wound vac, 10/8 wound vac placement, BP lightly low, sbp 80s, repeat upon laying down sbp 100's, held ace, bb, laxis for today. May consider amputation if not healing
10/9 2 central toes gangrenous, wound not improving.
Current meds: insulin regular human, vanco, clopidogrel, atorvastatin, insulin nph human, tamsulosin, sodium cl, docusate, heparin
VS
10/8/14
BP 127/72
HR 90
T 98.6
RR 20
O2 RA 97%
10/9/14 0752
BP 122/73
89
99.3
RR 16
o2 RA 95%
PAIN 3
10/9/14 1126
95/61, HR 74, TEMP 97.5, RR 16, O2 RA 99%
10/9/14 1600
98/58, HR 75, PAIN 2, TEMP 98, RR 18, 02 100%
wound culture was - for staph and enterococcus
HGBA1C 8.4 on 7/7/14
his BNP was extremely high but because I lost my patient's info, I don't know the exact number
his left foot is bandaged. right foot pedal pulse diminished, popliteal pulse felt, skin warm, caprefill
his recent labs:
10/9/14
WBC 10.8, HGB 9, HCT 25.8, PLT 341, NA 131, K 5.4 , then retaken and at 4.7, CL 102, BUN 24, CREAT 1.29, GFR 56
So my nandas that I am thinking of so far are
impaired tissue perfusion (peripheral)
decreased cardiac output
infection
fluid vol overload
impaired nutrition, more than body requirements
am I going in the right direction? I also get stuck on my inferences and the R/T part...
Any help would be GREATLY appreciated!!
