concept map in cellulitis

Nursing Diagnosis #05: Risk for bleeding related to post wound debridement procedure.
Objective cues:
Invasive procedure done: Debridement
(+)Tissue trauma
Vital Signs
Temp: 36.4 C
BP: 120/80 mmHg
PR: 80bpm
RR: 21 bpm
Pain Scale: 0/10
Facial Grimace
Nursing Diagnosis #06: Risk for situational low self-esteem related to change in body image
Subjective cues:
“Namamaga yung paa ko”
“Hindi ako makagalaw masyado..”
Objective cues:
Invasive procedure done: Debridement
(+)Tissue trauma
Facial Grimace
Limited range-of-motion
Seen to be resting on bed with right foot elevated using two pillows
Concept Map Care of a client with Cellulitis Nursing Diagnosis No#3: Activity intolerance related to inflamed wound on the right foot as evidenced by need of assistance in performing activites of daily living.
Subjective cues:
•“Hindi ako makagalaw masyado..”
Objective cues:
•Limited range-of-motion
•Seen to be resting on bed with right foot elevated using two pillows
•Contraptions: Heplock
Cellulitis s/p wound debridment of R Foot
Key Assessment Sketches * Medical Diagnosis
* Observation
* Patient Verbalization
* age
* weight
* Vital Signs
* Intake and Output
* Diet
*Medical Procedures done and laboratory results
*Physical Assessment
*facial Expression
*Contraptions
*Pain Assessment
*Physical Assessment
*Range-of-Motion Movement
*Medications
*Environmental conditions
*Presence of edema on foot
Nursing Diagnosis #01: Impaired peripheral tissue
perfusion related to poor oxygen supply on the
right foot as evidenced by pallor
Subjective Cues:
• “Namamaga yung paa ko”
Objective Cues:
• Invasive procedure done: Debridement
• (+)Tissue trauma
• Vital Signs
Temp: 36.4 C
BP: 120/80 mmHg
PR: 80 bpm
RR: 21 bpm
• Pain Scale: 0/10
• Facial Grimace Nursing Diagnosis #02: Impaired tissue integrity related to post wound debridement procedure as evidenced by presence of presence of fresh wound.
Subjective cues:
• “Namamaga yung paa ko”
Objective cues:
• Invasive procedure done: Debridement
• (+)Tissue trauma
Nursing Diagnosis # 04: Mild anxiety related to prolonged hospital stay as evidenced by facial grimace.
Subjective Cues:
• ”Gusto ko na umuwi.”
•“Sana gumaling na yung paa ko”
Objective Cues:
•Facial Grimace
•Perception regarding confinement
•Learning ability
•Emotional Response
•Vital signs: Temp: 36.4 C
BP: 120/80mmHg
PR: 80 bpm
RR: 21 bpm