Question

Create Concept Map and a Care Plan for impaired skin.

Patient Introduction:

Location: Skilled Nursing Home Care Facility 0800

Report from charge nurse:

Situation: Mrs. Morrow is an obese, 80-year-old white female who developed a venous stasis ulcer on her right medial malleolus while still living at home. She moved into our skilled nursing home care facility 3 days ago. The current plan of care is focused on promoting wound healing, improving venous return, and preventing skin breakdown.

Background: Mrs. Morrow has a past medical history of chronic obstructive pulmonary disease (COPD), chronic venous insufficiency, and deep vein thrombosis (DVT). Peripheral arterial disease is ruled out by duplex ultrasound. Her daughter had her admitted to this skilled nursing home care facility due to concern for her safety with impaired mobility, an unhealthy diet, and inability to adequately care for herself at home.

Assessment: Mrs. Morrow is alert and oriented, but sometimes forgetful of recent events. Vital signs have been within normal limits and are performed weekly. Results from yesterday's labs are in the chart. She is on a regular diet with nutritional supplement and has been eating the majority of her meals since admission. She requires assistance with positioning in bed and assistance times 1 to get out of bed to the chair or ambulate. Her gait is unsteady, and she is easily fatigued. Her Braden Scale score is 16, and her skin is intact except for the venous stasis ulcer on the right medial malleolus. She has brown hyperpigmentation on both lower legs with +2 edema. The venous stasis ulcer is covered with a hydrocolloid dressing, which is due to be changed. In preparation for her dressing change, she was medicated for pain half an hour ago.

Recommendation: You should complete a basic assessment, review the labs, perform a wound assessment and dressing change, and then reposition the patient to optimize venous return. Please provide patient education on improving venous return to prevent further stasis ulcers, and continue compression therapy with the use of elastic bandage and an antiembolism stocking.

The concept I created was not good, I need more details and organize it on the right places.

Please help!

Category Points Description Pe Identification of primary reason for seeking care 5 Identifies reason for seeking care and the primary medical diagnosis & patient initials Identify patient assessment data 10 Identify pertinent patient assessment data & cluste into physiological/psychosocial systems. (Data should include Pt. history, assessments, medications test results, lab values) Identification of 4 nursing diagnoses on concept map 10 Identify a minimum of four nursing diagnoses each written in complete diagnostic statements and place over appropriate cluster. (Nsg Dx/ rt/ aeb.) Prioritize Problems 5 Number nursing diagnoses in order of priority Nursing Diagnosis) 5 Write the priority nursing diagnosis on nursing care Identify priority problem plan in a complete diagnostic statement. 15 Identify a goal & outcome objective to be achieved Identify outcome objective and goal for one priority problem for the priority diagnosis. Outcome objective (short-term goa should be reasonable, measureable and time limited. 25 Identify 5 patient specific nursing interventions to Identify nursing interventions to achieve the outcome objective achieve the outcome objective. Each intervention needs a rationale. nse to 10 Identify how well the interventions worked. What Evaluation of Plan of 10 Was the outcome objective met? Does it need Clarity of Writing 5 Use standard English grammar with no spelling Patient Response is the patient response for each intervention? revision? How would you revise the plan? errors, neat and organized. intervention Care Total: 100

Answer 1

Client Initials: Mrs.Morrow

Age: 80 years Gender:Female Room Admit Date : Three days back

CODE Status N/A Allergies:N/A

Diet : Regular diet

Activity: Needs extensive assistance

Braden Score : 16 at medium risk for pressure ulcer

Admitting Diagnoses/Chief Complaint: Venous stasis ulcer on her right medial malleolus

Assessment Data:

Chief complaints: Presence of Venous stasis ulcer in her leg

Present illness history : Mrs.Morrow is alert and oriented but forgets some recent events.She has unsteady gait ,so she needs extensive assistance while performing activities of daily living and she is easily fatigued. Braden Scale score is 16 which indicates she is at risk for pressure ulcer and her skin is intact except for the venous stasis ulcer on the right medial malleolus. She has brown hyperpigmentation on both lower legs with +2 edema.

Surgical history: N/A

Medical history:  Her past medical history is she has chronic obstructive pulmonary disease (COPD), chronic venous insufficiency, and deep vein thrombosis (DVT). Peripheral arterial disease is ruled out by duplex ultrasound.Now admitted due to presence of venous stasis ulcer in right leg and requiring wound dressing. She needs assistance to carry out activities of daily living.Pain may be present in legs so kept elevated for improving circulation.

Family history: N/A

General - Not acute distress

Eyes - PERRLA

ENT - No discharge or abnormalities

Neck - No lymph node enlargement

Lymph Nodes - No lymphadenopathy

Cardiovascular - No chest pain, no palpitation, no shortness of breath ,but signs of fluid overload present

Lungs - Clear to auscltation,wheezes present.

Skin - No rashes, skin warm ,dry. Skin in legs is cool and has brown hyperpigmentation on both lower legs with +2 edema and venous stasis ulcer present in right medial malleolus.

Abdomen - Normal bowel sounds

Genito Urinary – No complaints but needs assistance for toiletting .

Rectal – Needs assistance for going to bathroom

Extremities - Slight indentation edema present in lower legs. Peripheral pulses feeble and hypepigmentation is seen in lower legs with ulcer in right leg. Needs assistance for walking .Antiembolism stocking applied in left leg

Musculo Skeletal - 3/5 strength, weakness and unsteady gait.

Neurological – Alert and oriented x 3 patient is alert and oriented to person, place, situation.

Vital signs: Normal but tachypnoea may be present

Medications:Tab. Aspirin 81mg PO ,Albuterol inhaler 300mcg, Zinc vitamin supplement, Acetaminophen 650mg PRN.

Antiembolism stocking in left leg and dressing foe wound in right leg.

Lab Values/Diagnostic Test Results:

Serum electrolytes:

Na+ 142; K +3.9,HCO3-28, Cl 102.

May be due to COPD she is at chronic respiratory acidosis.

Treatments:

Application of anti embolism stockings, dressing for wound and application of hydro colloid dressing over wound. Elevation of both extremities. Normal diet with nutritional supplements.Local wound management supported by formulary and clinical expertise.Management of surrounding skin to reduce further deterioration.

Primary Nursing Diagnosis:

• Ineffective peripheral tissue perfusion related to compromised circulation as evidenced by presence of brown pigmentation in legs, and edema.
• Activity intolerance related to weakness in limbs as evidenced by her necessity of assistance to carry out activities of daily living due to old age
• Fatigue related to old age as evidenced by her activities  inability to maintain usual routines
• Risk for impaired skin integrity related to venous ulcer as evidenced by brown pigmentation in skin and braden scale score of 16.