Help!! Nursing care plan cellulitis, edema, anemia, and chronic thrombocytopenia

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Help please! I have a concept map due tomorrow and I am stuck.

My pt. is a 79yr old Caucasian male. His admitting diagnosis was cellulitis, dependent edema, renal insufficiency, and chronic thrombocytopenia. Has a history of acute renal failure, anemia, disuse myopathy, gout, HTN, and hyperkalemia.

Labs

WBC 2.2 (normal range 4.8-10.8)

RBC 2.19 (4.7-6.1)

Platelet 33 (130-400)

Hgb 7.7 (12.6-17.4)

Hct 22.4 (37-57)

MCV 102 (80-94)

MCH 35 (27-31)

Vitals: T 97.1-99.7, HR 73-93, RR 18-20, O2 93-98, BP 117/54-126/72

Non-pitting edema, 1+ right foot. Pt. states that symptoms(pain) are made worse when standing. Redness and swelling present in both feet.

My pt. received 1bag of PRBCs and 2 units of platelets. He tolerated it well. VSS.

I don't know where to start or how to prioritize my nursing diagnosis'. So far I have:

-Risk for infection r/t inadequate secondary defenses to anemia.

-Risk for impaired skin integrity r/t inflammatory process damaging skin

-Ineffective tissue perfusion: peripheral r/t edema

Someone please help me get on the right track and to come up with some more nursing diagnosis'! I am stumped for some reason.

Blue Cat

87 Posts

Do you have a nursing diagnosis book? I would look up the admitting dx's and see what nursing dx's they correlate to.

Blue

xtxrn, ASN, RN

4,266 Posts

Help please! I have a concept map due tomorrow and I am stuck.

My pt. is a 79yr old Caucasian male. His admitting diagnosis was cellulitis, dependent edema, renal insufficiency, and chronic thrombocytopenia. Has a history of acute renal failure, anemia, disuse myopathy, gout, HTN, and hyperkalemia.

Labs

WBC 2.2 (normal range 4.8-10.8)

RBC 2.19 (4.7-6.1)

Platelet 33 (130-400)

Hgb 7.7 (12.6-17.4)

Hct 22.4 (37-57)

MCV 102 (80-94)

MCH 35 (27-31)

Vitals: T 97.1-99.7, HR 73-93, RR 18-20, O2 93-98, BP 117/54-126/72

Non-pitting edema, 1+ right foot. Pt. states that symptoms(pain) are made worse when standing. Redness and swelling present in both feet.

My pt. received 1bag of PRBCs and 2 units of platelets. He tolerated it well. VSS.

I don't know where to start or how to prioritize my nursing diagnosis'. So far I have:

-Risk for infection r/t inadequate secondary defenses to anemia.

-Risk for impaired skin integrity r/t inflammatory process damaging skin

-Ineffective tissue perfusion: peripheral r/t edema

Someone please help me get on the right track and to come up with some more nursing diagnosis'! I am stumped for some reason.

OK :)

Risk for infection: what other lab test show a risk for infection (generally, RBCs and H&H aren't going to be the big ones)

Cellulitis- already has an infection- so what complications do you need to address?

- skin integrity already effected

What other issues can anemia cause?

Do you have the potassium level?

Pain is always important to address if there are diagnoses with probable pain :)

Risk of blood loss (thrombocytopenia)

Fluid imbalance - renal failure, edema

What issues are there with decreased mobility? (has myopathy from disuse)

THEN, what order do they need to be in - ABC, then Maslow's.....

See what you come up with :)