hi, i'm a first semester nursing student and i have been having trouble trying to do my care plans this week.i usually get them done without any trouble, but for some reason i just cannot think of diagnoses for my patient:confused:.once i get the diagnosis down i'm usually good.i'll give you some information on my patient....
my patient was admitted to the emergency room after waking up with severe foot pain.she had an emergency pcta, sfa, and popliteal done.(percutaneous transluminal coronary angioplasty, superficial femoral artery and popliteal artery)after assessment and diagnostic testing it was confirmed that patient had an ischemia to the left lower limb as a result of arteriosclerosis and required ptca, sfa & popliteal surgery to restore circulation to the extremity.she has a sore on her left foot that was confirmed as cellulitis.wound care was done on her left foot this morning. patient wound measures 1.5mm x 1mm (length and width) with the depth
skin break down.
patient has a medical history of htn, dm, vascular dementia, gastroparesis, tia, cva, gerd, anemia, gastritis, cad, djd, bipolar disorder and pyuria. patient's surgical history includes bilateral carotid aterectomy. patient denies any history of smoking tobacco or alcohol consumption.
vitals- t-97.8, bp 95/63, pulse ox 96%, pulse 69, her blood sugar was 116.(she is diabetic)
lab values- glucose-163, co2-20, wbc-2.9, hemo-10.8, hemat-32.9.
she rates her pain a 5/10.it is aching when sitting and sharp when applying pressure.
we have to do a care plan on the neurosensory system and cardiopulmonary.
i was thinking acute pain related to inflammation of ulceration wound site as evidenced by patient demonstrating facial grimacing when applying pressure to her lower left extremity and patient stating "my pain is a 5/10."-nuerosensory.i'm not sure if that would be a correct diagnosis?
i cannot think of anything for cardiopulmonary....possibly , impaired tissue integrity related to altered circulation..would that be one?
any help is greatly appreciated, i'm having such a tough time on these!