Nursing Care Plan
Medical Diagnoses:Acute cellulitis of bilateral lower extremities with necrosis;
hyponatremia; community acquired pneumonia
Chronic Health Conditions & Previous
Right>Left pleural effusion; Chronic A
Fib; Chronic Renal Insufficiency; Hypokalemia; Constipation; Traumatic Pneumothorax
x2 thoracentesis; cellulites bilateral with necrosis
ambulate with walker and assist with clinical assistant
Reason for Admission [residents own words]:
n/v for 5 days and went to the hospital and
got pneumonia, and got cellulites in both lower extremities
I & O:
Client is encouraged to consume fluids. Voids while using the urinal
Medical Diagnosis [medical terms]:
Pain in lower extremities; pain in right
dressing change on bilateral lower extremities once a day
Acute cellulitis of bilateral lower extremities
with necrosis; hyponatremia; community acquired pneumonia
Date of admission:
Nursing Diagnoses (3. prioritized)
1. Risk for infection r/t tissue destruction
ABE breakdown on the sacrum
2. Risk for impaired skin integrity r/t diabetes AEB lesions and sores on lower
3. Risk for ineffective tissue perfusion
r/t impaired arterial circulation AEB 2+ edema bilateral on lower extremities
4. Risk for fall r/t impaired mobility AEB
weight bearing pain on bilateral lower extremities
5. Risk for toileting self-care deficit r/t
impaired mobility AEB need for assistance when ambulating
23 years old
24 years old
*other Combvient Inhaler
Type II Diabetes
X sliding scale insulin
No Known Allergies
Discharge Plan/ Long Term Goals:
Regain strength to walk with out a walker
Describe pathophysiology of primary
Cellulitis: it is an infection of the dermis and subcutaneous tissue. It is an infected
area that is warm, erythermatous, swollen, and painful. The infection is usually
in the lower extremities and responds to systematic antibiotics. To help with pain,
Burow soaks is implemented (Huether, 2008).
develops when the serum sodium concentration falls below 135 mEq/L. Sodium deflects
usually causes hypoosolality with movement of water into the cells. Pure sodium
deficits usually are caused by extrarenal losses, such as vomiting and diarrhea.
This alters the cells ability to depolarize and repolarize normally. Pure sodium
loss can be accompanied by loss of extra cellular fluid which can cause isotonic
hypovolemia (Huether, 2009)
Why does resident receive?
Major Side Effects
500 mg tablets
2 tablets PO Q4
Mild pain and if temp reaches over
rash, acute poisoning, anorexia, nausea,
vomiting, dizziness, lethargy, hepatotoxcity, hepatic coma, acute renal failure
monitor for signs and symptoms of
hepatoxcity even with moderate acetaminophen doses, especially in individuals with
poor nutrition or who have ingested alcohol over prolonged periods.
One application to feet BID
Acute Cellulites to bilateral feet
urogenial: vulvovaginal burning, itching,
or irritation; maceration, allergic contact dermatitis
expect clinical improvement from topical
application in 1-2 weeks.
8.6-50 mg tablets
1 tablet PO BID
abnormal cramps, flatulence, nausea,
watery diarrhea, excessive loss of water and electrolytes
reduce dose in patients who experience
considerable abdominal cramping.
the drug may alter your urine and
5 mg PO Q day
Diabetis Mellitus Type 2
hypersensitivity to sulfonylureas,
observe response to initial dose,
lab test to monitor liver function, check urine for sugar and ketone bodies, hypoglycemia
maybe hard to detect at first.
80 mg PO Q day
postural hypotension, dizziness, circulatory
collapse, hypovolemia, dehydration, hyponatremia
closely and monitor blood pressure
and vital signs, monitory s/s of hypokalemia, with older adults: observe periods
of brisk diuresis, sudden alteration with fluid and electrolyte imbalance, lab test
for frequent blood count, monitor I&O, monitor urine blood glucose in urine
2.5 mg PO Q day
A-fib and prophylactic
major or minor hemmerages form any
organ and tissue, anorexia, nausea, vomiting, abdominal cramps,
determine PT/INP prior to initiation
of therapy, obtain careful medication history prior to start of therapy, lab test
50 mg 1 tablet PO Q bedtime
drowsiness, dizziness, insomnia, headaches,
agitation, hypotension, dry mouth, weight gain and loss
monitor pulse rate, monitor for change
in behavior, observe patients level on activity, check for s/s of hypotension,
10 mg 1 tablet PO Q day
fatigue, pain, dizziness, headache,
abdomen pain, sinusitis, upper respiratory infection
monitor CV status and blood pressure,
check postural vital signs to evaluate for orthostatic hypotension, check labs for
baseline and periodic LFT's
back pain, asthenia, headache, constipation,
diarrhea, increased liver function, rash
monitor therapeutic effectiveness
which is indicated by reduction in the level of LDL-C, check labs for lipids levels,
asses for muscle pain, monitor for digoxin toxicity with current digoxin use.
50 mg PO Q day
red rash, fever, headaches, muscle
aches, sore throat, dizziness, fatigue, insomnia, bradycardia, heartburn, shortness
apical pulse and blood pressure because
admin of drug, take several blood pressure readings, monitor I&O, daily weight,
20 mcg 1 tablet PO BID
nausea, vomiting, diarrhea, abdominal
distension, pain, mental confusion, irritability
monitor I&O ratio, check lab for
serum, electrolytes are warranted, monitor for and report signs of GI ulceration,
monitor potassium, , also patient has a risk of hyperkalemia.
All information from the: Prentice Hall Nurse’s Drug Guide
2009, By: Wilson, Shannon, Shields
1. Risk for infection r/t tissue destruction ABE breakdown
on the sacrum
2. Risk for impaired skin integrity r/t diabetes AEB lesions and sores on lower
3. Risk for ineffective tissue perfusion r/t impaired arterial
circulation AEB 2+ edema bilateral on lower extremities
4. Risk for fall r/t impaired mobility AEB weight bearing
pain on bilateral lower extremities
5. Risk for toileting self-care deficit r/t impaired mobility
AEB need for assistance when ambulating
Pertinent Lab/Diagnostic Test Results and date of exam:
0.48 SI units
0.42-0.52 SI units
VS: BP: 135/ 85
heart rate: 86 Temperature
97.6 Respirations: 18
Musculoskeletal Activity: unsteady gait
and able to perform tandem walk with assistance of walker, negative Romburg sign.
Joints and muscles symmetric; no swelling or deformity; normal spinal curvature
with slight kyphosis; no tenderness to palpation of joints; heat with swelling in
both legs and feet. ROM: smooth movement except right shoulder, left knee- tenderness
and limited movement and decrease flexion of them. Rest of ROM are smooth movement,
no tenderness, no creptius, muscle strength- able to maintain flexion against resistance
and without tenderness.
Skin : warm and dry and has excessive bruising
due to diagnosis of diabetes, breakdown on sacrum, good skin hygiene everyday. Skin
is pallor with no clubbing, moles on arms, legs, and chest bilaterally, very few
lesions on lower extremities.
Cardiac: No lifts,
heaves, or thrills, the cardiac apical impulses, it is located in the 5th
ICS, MCL with a short genital tap with the measures of 1cmx2cm. S1 and S2 are present
in all five cardiac areas with no extra beats or sounds, but with a slight irregular
beat. Client is negative for JVD. Pulses: 2+ radial, 2+ ulnar, 2+ brachial, 1+ femoral,
1+ popliteal, 1+ posterior tibialis, 1+ dorsalis pedis. Client has 2+ edema on right
foot and 1+ on left foot with warmth to touch.
Pulmonary: Client has
a dry productive cough with transferring, no pain with breathing and smoked for
about 50 plus years and quit due to medical reasons; no history of lung disease.
No bulging or retraction and symmetric with expansion. Resonance heard throughout,
no adventurous sounds or crack or wheezes. The right shoulder is slightly higher
than the left shoulder with pallor skin. No tenderness or creptius, a positive tactile
fremitus. Chest expands posterior symmetrical with a resonance of the lungs with
percussion. No adventurous sounds, cracks, or wheezes. His respiratory rate was
GI / Nutritional Status: Client states
no changes in appetite, difficulty swallowing, abdomen pain, nausea or vomiting,
or past histories of abdominal surgeries or diseases. With inspection on the abdomen,
pallor, no lesions, midline and inverted umbilicus with no signs of discoloration
or inflammation and no hernias, no bruits, bowel sounds positive in all four quadrants.
states that he is weak and tired all the time. Client states that he has pain when
walking around and that his legs stay swollen and that there are cracks/sores on
Cellulitis with necrosis
bilaterally to lower extremities.
3+ edema in left lower extremities and 2+ edema in the right lower extremities.
Type II Diabetes,.
Lesions on bilateral lower extremities.
Risk for impaired skin integrity
Verbalize a personal plan for preventing
impairs skin integrity on [date] at 1130.
For a client
with limited mobility, monitor condition of skin covering bony prominences.
ulcers usually occur over bony prominences, such as the sacrum, coccyx, and heels.
This is a result of unrelieved pressure between the prominences and support surface
(Maklebust & Sieggreen, 2001; WOCN, 2003).
Teach the client
skin assessment and ways to monitor for skin breakdown.
assessment and intervention helps prevent the development of serious problems. Basic
elements of a skin assessment are assessment of temperature, color, moisture, and
intact skin (Baranoski & Ayello, 2003).
Client will be taught what a part of his body is at most risk for skin break down.
He will also be taught how to do a simplified skin assessment and what to look for
if there is a breakdown or change in skin.
observes the material being taught and made sure it was taught in a simple manner
so that it was not to complex for the client. Nursing student will observe the client
doing his own simplified skin assessment.
Client will be able to report any altered
sensations or pain on bilateral lower extremities after teaching on [date] at 1630.
Monitor skin conditions at least once a
day for color or texture changes, or lesions. Determine whether the client is experiences
loss of sensation or pain.
Rationale: systematic inspection can identify impending problems early (Ayello & Braden,
2002; Krasner, Rodeheaver & Sibbald, 2001).
Limit the number complete baths to two or
three per week, and alternate them with partial baths. Use a tepid water temperature
(90 and 105 degrees) for bathing.
Rationale: excessive bathing, especially
in hot water, depletes again skin of moisture and increases dryness. The ability
to retain moisture is decreased in the skin and starts to diminished amounts of
dermal proteins. One of the most common age-related changes to the skin is damage
to the stratum corneum (Baranoski, 2000; Ayello & Braden, 2003).
Client will be taught what to look for and
how to inspect his own legs and will be able to demonstrate a self inspection of
his lower extremities and be able to report is pain on a scale from 0-10.
Nursing student observes the client in doing
a self inspection of his lower extremities. Client was able to report his findings
and knows to report is there are any new ones.
Client also understood the importance of
a pain scale and new how to implement it on a scale from 0-10.
Lesions and sores on bilateral lower extremities
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