Published Dec 1, 2009
NSC11
8 Posts
Hi all! Ok so I'm stuggling trying to figure out nursing diagnoses and the order if which they would go for my client with left foot and leg cellulitis. Here is his history: 45 yo male. he was admitted the night before which according to him "he had an infection on his foot," he is up and ambulating fine, doesn't complain of pain and isn't on any PRN pain meds but says he is a little sore, his left lower leg and foot are inflamed- they are reddened, extremely warm to touch compared to his other leg and rest of the body, he has alot of swelling, and a part on the left lateral side of his foot is ulcerated. He says he doesn't have much feeling in that foot, and he wanted his foot elevated with 3 pillows on the bed. He didn't having a dressing on it, but the doctor called right before I left and was concerned that it wasn't covered so we covered it. He is on antibiotics. He has type 2 diabetes and cardiac disease, and had a stent placed a few months ago - this is his only medical history. His lungs sounds are clear, his breathing is regular and unlabored, his heart sounds are normal, and bowel sounds are normoactive. The rest of his body is normal temperature and the color is wnl. Radial pulses and pedal pulses are all present and palpable, even in the left foot. His vital signs are all within normal range except his BP was elevated some to 148/80 around noon. Lab values were all within normal range except chloride was a little low.
I've read many entries on here about cellulitis, and some seem very contradicting. Some say it's acute pain and impaired skin integrity, others say it's not impaired skin integrity. Some say its impaired tissue integrity (along with my book), while other entries say it's not impaired tissue integrity.
Can someone PLEASSSEE help me with this? I know impaired skin integrity is one of the diagnoses for him because the left lateral side of his foot is ulcerated, but would impaired tissue integrity be one also? or ineffective tissue perfusion - peripheral? Ineffective tissue perfusion peripheral is pale skin, cold extremeties though - and that's opposite of my client. I've seen all these being used - and they are very similar so I'm unsure as to which is right, along with the order they would go in. yikes
pleasssee help by tomorrow morning :) thanks!