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Patient Data

Therapeutic Modalities

Patient Initials: J.

Age: 42

Date of Admission: 4/12/2016

Admitting Medical Diagnosis: Complex wound infection, end-stage renal disease (ESRD)

Surgical Procedures: Groin thrombectomy, right leg amputation, peripherally-inserted central catheter (PICC)

Pertinent Health History: hypogylcemia, type II diabetes, progressive angina, coronary artery disease, cardiomegaly with mild pulmonary edema, thrombocytopenia

Pertinent Signs and Symptoms: pus draining from the wound, foul odor, throbbing pain at the wound site; edema in lower extremities, inability to urinate, loss of appetite

Diet: NPO

Activity: Bedrest

Vital Signs: 97.3, 68, 18, 107/49, 10/10, 99%

Priority Nursing Diagnosis

Care Plan

Priority Nursing Diagnosis Statement

Impaired skin integrity related to a pressure ulcer on sacrum as evidenced by epidermal and dermal tissue disruption and evidence of bone exposure

Source: Pressure Ulcer Staging. (n.d.). Retrieved April 19, 2016, from http://woundconsultant.com/sitebuilder/staging.pdf

Clarifications and Questions

Correlation to Pathophysiology

Evaluation

Goal has been partially met. Patient demonstrates enhanced knowledge but skin has not regained integrity.

  • End-stage renal disease is the last stage of chronic kidney disease. This is the point in which the kidneys can no longer support the body's needs. ESRD may need to be treated with dialysis or a kidney transplant.
  • A thrombectomy is "a surgical procedure used to remove a blood clot (thrombus) from a vessel" (MD Guidelines). Thrombectomy is generally only performed when there is arterial thrombosis, that is limb-threatening. Blood clots that may be removed using thrombectomy include those arising in the large artery of the hip and thigh (iliofemoral artery) and the artery beneath the clavicle (subclavian artery).

Laboratory and Diagnostic Studies

  • Prealbumin (PAB) 5 mg/dL
  • Normal range 19-38 mg/dL
  • Indicates severe protein depeletion
  • WBC 12.93 billion cells/L
  • Normal range 3.5-10.5 billion cells/L
  • Indicates infection
  • RBC 2.46 trillion cells/L
  • Normal range 3.90-5.03 trillion cells/L in females
  • Indicative of anemia
  • Hemoglobin (HgB) 7.4 L
  • Normal range 12-15.5 grams/dL
  • Indicative of anemia

Many factors, including pressure, friction, shearing forces and moisture contribute to the development of a pressure ulcer, but pressure leading to ischemia and necrosis is the final common pathway. Pressure ulcers result from constant pressure "sufficient to impair local blood flow to soft tissue for an extended period of time" (Medscape).

Source: Kirman, C. N., & J. G. (2015, April 1). Pressure Ulcers and Wound Care. Retrieved April 19, 2016, from http://emedicine.medscape.com/article/190115-overview#a4

Source: Hospital Acquired Pressure Ulcers - Who is to Blame? (2015, April 20). Retrieved April 19, 2016, from http://decubitusulcervictims.com/hospital

Priority Nursing Diagnosis Care Plan

Sources:

  • Thrombectomy. (n.d.). Retrieved April 25, 2016, from http://www.mdguidelines.com/thrombectomy
  • End-stage kidney disease: MedlinePlus Medical Encyclopedia. (2015, September 22). Retrieved April 19, 2016, from https://www.nlm.nih.gov/medlineplus/ency/article/000500.htm

Goal Statement

Interventions

  • Nurse will monitor site of skin impairment at least once a day for color changes, redness, swelling, warmth, pain or other signs of infection.
  • Nurse will turn patient every 2 hours.
  • Nurse will keep the skin clean and dry.
  • Nurse will provide appropriate wound care.
  • Nurse will educate patient on skin and wound assessment and ways to monitor for signs and symptoms of infection, complications and healing.
  • Nurse will educate patient on wound hygiene and care.
  • Patient demonstrates an understanding of plan to heal skin and prevent reinjury by the end of the shift.
  • Patient will report any altered sensation or pain at site of skin impairment throughout hospitalization.
  • Patient will regain integrity of skin surface by discharge.

Source: Nursing Interventions and Rationales. (2013, July 30). Retrieved April 19, 2016, from http://nursinginterventionsrationales.blogspot.com/2013/07/impaired-skin-integrity.html

Medications

  • Cefepime
  • Antibiotic
  • Amiodarone
  • Ventricular tachycardia
  • Humulin
  • Diabetes
  • Toprol
  • Beta-blocker, angina
  • Nitrostat
  • Angina
  • Ondansetron
  • Anti-nausea
  • Hydromorphone
  • Pain

Nursing Diagnoses

1) Acute pain related to wound on leg as evidenced by patient rates pain level of 10/10.

2) Disturbed body image related to right leg amputation as evidenced by verbalization of feelings of self-worthlessness.

3) Impaired skin integrity related to pressure ulcer as evidenced by open leision.

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