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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%
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
Goal has been partially met. Patient demonstrates enhanced knowledge but skin has not regained integrity.
Laboratory and Diagnostic Studies
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
Sources:
Source: Nursing Interventions and Rationales. (2013, July 30). Retrieved April 19, 2016, from http://nursinginterventionsrationales.blogspot.com/2013/07/impaired-skin-integrity.html
Medications
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.