Question

Write a CARE PLAN - on patient with cellulitis in bil lower extremities , sleep apnea, and lymphedema. Pt. demographics ----- Pt. is always in bed , has bil lower limb stage 4 ulcers, has a Pacemaker, syncope, and oxygen cannula.Pt. Verbal and alert&orientedx4. Pt. vitals - temp.- 96.8*F , pulse - 76, respirations - 15, bp-149/67 , spo2- 92

Write a care plan - 3 Goals needed (long term and short term), 3 Nursing diagnosis with 5 Nursing intervention and rationale each

Answer 1

Cellulitis (sel-u-LIE-tis) is a common, potentially serious bacterial skin infection. The affected skin appears swollen and red and is typically painful and warm to the touch. Cellulitis usually affects the skin on the lower legs, but it can occur in the face, arms and other areas.

Nursing Care Plain ASSESSMENT | DIAGNOSIS | PLANNIG | INTERVE EVALUATION NTION INDEPEND >Identify S : "Namamaga Impaired skin SHORT at namumula ang integrity related TERM GOAL ENT kanang paa ko." to bacterial As verbalized byinfection as After 4 hours of rendering nursing To assess After 4 hoursunderlying causative the patinet.manifested byof rendering cause/condit ributing /contintervention, the client's mother participated in preventive measures and treatment programs for her the swelling of nursing the right foot. intervention,involved. factors. ion O: -swelling of the right foot -skin redness -skin lesions patient will be able to participate inchanges in extent of preventive Note To asses:s skin color,involvement/i child. asures andtexture and njury treatment program. turgor LONG TERM>Determine To assess GOAL: depth of injury/damainvolvement/iAfter week of extent of After 1 week ge to the client w integumenta be taught what ry system. a part of his body is at most >Inspet risk for skinskin on acorrecting/minextremities break down teaching the client, he is seen doing a self inspection of his njury To assist withlower daily basis,imizing ribing condition and lesions and promote changes observed. healing optimal >Keep the To assist body's natural area clean/dry, process of prevent infection, and stimulate circulation repair surrounding areas iew To promote importance of skin and wellness.

EVALUATION After 4 hours of intervention, the participated in measures and ASSESSMENT DIAGNOSIS | PLANNIG INTERVENTION S: "Namamaga at Impaired skin SHORT TERM INDEPENDENT namumula ang integrity related GOAL Identify underlying rendering nursing After 4 hourscause/condition As verbalized by infection as of rendering involved the patinet. manifested by nursing R: To assess the swelling of intervention causative/contributing preventive the right foot. patient will be factors. swelling of the in skintreatment programs able to participate in color, texture and turgor. for her child. R: To assess extent of measures and omentinjury -skin lesions >Determine depth of injury/damage to LONG TERM R: To assess extent of involvement/injury Inspect skin on a daily teaching the client, After 1 week basis, describing lesions he is seen doing a the client l and changes observed. self-inspection of be taught what R: To assist with a part of hiscorrecting/minimizing extremities. body is at most condition and promote risk for skin optimal healing. break down >Keep the area his lower clean/dry, prevent infection, and stimulate surrounding areas. R: To assist body's natural process of repair Review importance of skin and measures to maintain proper skin functioning R : To promote wellness. >Discuss importance of early detection of skin changes and/or complications. R: To promote wellness. >Assist client's mother in understanding and following medical regimen and developing program of preventive care and daily maintenance. R: Enhances commitment to plan,

Lymphedema

Lymphedema, or lymphatic obstruction, is a long-term condition where excess fluid collects in tissues causing swelling (edema).

The lymphatic system is a part of the immune system and vital for immune function. Fluid called lymph circulates within the lymphatic system. Lymphedema is typically caused by a blockage of this system.

Lymphedema commonly affects one of the arms or legs. In some cases, both arms or both legs may be affected. Some patients might experience swelling in the head, genitals, or chest.

Lymphedema is incurable, but with the right treatment, it can be controlled.

Nursing Care Plan Assessment Diagnosis Planning At the end of my shift the patient 1. Note factors affecting current situation and potential time involved Intervention Evaluation Independent: Impaired Goal partially met as evidenced Patient's wife physical verbalizedmobility R/T to will be able to dili siya kalihok pain secondary pagawas sa bed | to lymphedema |-perform activities | 2. Assess client's motor skills, ease and capability of movement kay sakit iyahang paa Rationale: helps identify potential impairments and determines type of interventions needed to provide for client's safety by patient activities of daily living with assistance and of daily living with assistance and determin Rationale: to determine presence of characteristics of client's unique impairment and to guide choice of intervention Rationale: tissue swelling without occurs in the 3. Assess degree of pain, listening to client's description about the manner minimal Obiective: left leg enlarged and because of an demonstrate swollen discomfort in which pain limits mobility Rationale: pain is a subjective experience and can't be felt by others Assess nutritional status of the patient Rationale: deficiencies in nutrients, water, electrolytes and minerals can negatively affect energy and activity tolerance Support affected body part using pillows Rationale: to maintain position and function and reduce risk of pressure discomfort, 4. techniques of behaviours that enable resumption of techniques of increased quantity of behaviours that enable 5. VS taken as lymph that follows: T: 36.3 P:88 R:17 BP: 130/70 results from obstruction of activities lymphatic vessels (textbook of medical surgical nursing, brunner and suddarth 13th edition) resumption of 6. Encourage adequate intake of fluids and nutritious foods Rationale: promotes well being and maximizes energy production Schedule activities with adequate rest periods during the day Rationale: to reduce fatigue Identify energy-conserving techniques for ADL's Rationale: limits fatigue, maximizing participation Encourage participation in self care, occupational, diversional or recreational activities Rationale: enhances self concept and sense of independence 7. 8. 9. 1. Administer medications prior to activities for pain as ordered Rationale: to permit maximal effort and involvement in the activity

Sleep Apnoea

Sleep apnea is a potentially serious sleep disorder in which breathing repeatedly stops and starts. If you snore loudly and feel tired even after a full night's sleep, you might have sleep apnea. The main types of sleep apnea are: Obstructive sleep apnea, the more common form that occurs when throat muscles relax.