Help w/ care plan (concept map)

I am having a hard time coming up w/three nursing dx, goals ect. for concept map.

Assessment: 85 yo F resident of a LTC admitted with cellulitis unresoved with oral antibiotics. Admitted for IV vancomycin. Renal imparment; only getting antibiotic every other day. Bilat LE deep purple, hot and tender to touch, +1 edema. A/O x1 not to time or place (knows she is not where she lives but not that she is in the hospital). Only other history I have is that she has organic dementia. She is a poor historian. No pain stated when asked, but does guard her legs. Speach clear, moves all extremities with equal strengh (very weak). Apical HR regular 67. Lungs clear. Abd soft, non tender bowel sounda present in all 4 quads. Has a foley, clear yellow urine, adequate output. Erythematous lesion under L breast (poss yeast infection) barrier cream applied. RN will ask Dr if nystatin powder in indicated. Pt has patent hep lock in L AC. She is a fall risk.

Vitals 0800

T 98.5

P 72

R 18

BP 134/66

1200

T 98.3

P 67

R 16

BP 127/64

We do consept maps. We have to give top 3 dxs, goal for each and 5 interventions that can be done. Here is what I have so far. Help would be appreciated!!! :-)

Dx: Cellulitis

PMH: Dementia, renal insufiency

Priority Assessments: VS, Skin, Mental Status, Urine output.

1. Impaired Tissue Integrity R/T (dont know) AEB bilat LE hot, tender to touch, + 1 edema, local pain.

Goal. Bilat LE tissue improves AEF decreased redness, swelling and pain.

Intervention

Antibiotics as ordered

Encourage adequate nutrition

2. Self Care Deficit R/T organic dementia AEB inability to toilet, transfer, bathe and groom self.

Goal: pt safely performs grooming tasks (to maximum ability)

Interventions

Use consistant routines and allow adequate time for tasks

Set short term goals.

Positive reinforcement.

3. Impaired Mobility R/T limited strength AEB Limited ROM, Decreased muscle endurence, strength

Goal Pt performs physical activity with assistive devices

Encourage ambulation

Turn and reposition every 1 1/2 to 2 hours.

passive and active ROM excersises.

Thanks for any input!!!