Etiologies: What causes this pathology? Asterisk those specific to this patient. List Meds used to manage this primary pathology. Asterisk thos

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Student Name __________________ Clinical Instructor ________________ Date ______________ Unit _________________ Pt Initials _________ Age/Race/Gender ___________

Primary Medical Dx and definition (1-2 sentences):

Etiologies: What causes this pathology? Asterisk (*) those specific to this patient. List Meds used to manage this primary pathology. Asterisk (*) those specific to this patient.

Diagram and discuss the Pathophysiology of the primary Medical Dx of the patient.

Signs & Symptoms: Asterisk (*) those that are present in this patient. List diagnostic tests used to manage this pathology: Asterisk (*) those that are actual in the patient.

Include APA Reference List and in-text citations.

Adalinda Elizondo 09-20-2020

Virtual Clinical S.J. 88 yrs/ African American/ Female

Sachwani

The patient has type 2 diabetes mellitus and due to the illness she has developed poor circulation rendering the wound to receive the nutrients it needs to heal thus delaying the healing process. Hyperglycemia leads to osmotic diuresis and subsequent decreased oxygenation and perfusion. High blood glucose causes stiffening of the arteries, narrowing of blood vessels, and diabetic neuropathy, which is nerve damage throughout the body, particularly the limbs.

Increase pain on the wound. Redness around the wound. Warmth around the wound. Necrosis is present. Underlying structures becoming visible (tendon, bones, muscle) Minimal granulation. Inflammation. Large amount of exudate (serous, sanguineous, purulent) Poor wound edges. Erythema on the peri- wound skin. Excoriated peri-wound skin.

Gabapentin 300 mg PO TID *Insulin glargine, 26 units Subq *Insulin aspart, 1 unit for 10g carbs Simvastatin 40mg PO qPM

Poor wound healing of right below the knee amputation (BKA).

The cause of this pathology which is improper wound healing is due to the patient’s underlying medical complications. Poor wound healing is when the body is not able to supply the wound with sufficient nutrients to help aid in healing.

*CBC *Wound Culture and Sensitivity *Serum Glucose

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Initial Assessment Data r/t Priority Nsg Dx: Highest Priority Nursing Dx: Plan: S/T Goal: Interventions:

Rationale for Nsg Dx #1 (number items to correspond with interventions; cite/quote references and page numbers): Evaluation:: Skills Used for this Nsg Dx: Explore potential Legal/Ethical Issues r/t caring for patient:

Risk for infection related to compromised host defenses secondary to diabetes mellitus.

Risk for falls related to loss of limb.

Risk for infection related to compromised host defenses secondary to diabetes mellitus.

The person will report risk factors associated with infection and precautions needed, as evidenced by describing the influence of nutrition on prevention of infection.

Assess nutritional status to provide adequate protein and caloric intake for healing.

Maintain aseptic technique for all invasive devices, changing sites, dressings, tubing, and solutions per policy guidelines.

Assess the individual's personal hygiene habits; correct any be havior that increases risk for infection.

Explain that the usual signs of infection may not be present (e.g., fever, chills).

All people are at risk for infection. Secretion control, environmental control, and hand washing before and after individual care reduce the risk of transmission of organisms (Carpenito, 2019).

Patients whose host defenses are compromised, thus increasing susceptibility to environmental pathogens or his or her own endangers normal flora (Carpenito, 2019).

Monitor temperature every 4 hours; notify physician/NP if temperature is greater than 100.8° F.

Patients should notify their physician if a fever is present because this is sometimes the only sign of an infection (CDC, 2019).

Promote wound healing for people with diabetes, control blood sugar levels to help prevent wounds from developing and to support healing and recovery (Grieger, 2019).

Goal was successfully met as the patient was able to perform a return demonstration on proper sterile dressing change on wound and verbalized adequate food groups for nutrition intake.

Beneficence related to doing what is in the best interest of the patient and taking positive actions to help keep the patient’s wound free from infection.

Impaired physical mobility related to loss of limb.

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Use back of page as necessary for all sections. Initial Assessment Data for 2nd Highest Nsg Dx: Nsg Dx #2: Plan: S/T Goal: Interventions: Cite reference with item.

Rationale for Nsg Dx #2 (number items to correspond with interventions; cite/quote references and page numbers): Evaluation: Skills Used for this Nsg Dx: Safety Concerns when caring for this patient:

APA Reference List on back of page:

The patient has a below the knee amputation and will need to teachings on methods to properly move independently within the environments such as bed mobility, transfers, ambulations.

Impaired physical mobility related to loss of limb.

The individual will report increased strength and endurance of limbs, as evidenced by the use of safety measures to minimize potential for injury.

Teach the patient to perform active ROM exercises on unaffected limbs at least four times a day.

Explain the purpose of progressive mobility, passive and active ROM exercises.

Refer to ROM exercises with photos for specific instructions and photos of passive ROM .

Provide written instructions for prescribed exercises after demonstrating and observing return demonstration.

Medicate for pain as needed, especially before activity.

Ensured patient’s safety by proper positioning the patient and hospital bed when using the Hoyer lift when moving patient in and out of bed.

Patient was able to perform active ROM successfully and performed return demonstration on passive ROM independently on the upper extremities and the left limb.

Performing ROM exercises is essential for the patient to prevent deep vein thrombosis and muscle atrophy (Carpenito, 2019).

Prolong sitting can put the patient at risk for left leg amputation due to poor circulation from sedentary lifestyle and peripheral neuropathy (Terranova, 2015).

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Date Progress Notes

References:

Terranova, A. (2015). The effects of diabetes mellitus on wound healing. Plastic surgical nursing : official

journal of the American Society of Plastic and Reconstructive Surgical Nurses, 11(1), 20–25.

Grieger, L. (2019). Five nutrition tips to promote wound healing. Eat right: academic of nutrition

and diabetes. Retrieved on September 21, 2020, from www.eatright.org.

Carpenito, L. (2019). Handbook of nursing diagnosis. (15th ed.) (p.g. 305, 329, 336). Walters

kluwer publishing.

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1

Student Name __________________ Clinical Instructor ________________ Date ______________

Unit _________________ Pt Initials _________ Age/Race/Gender ___________

Primary Medical Dx and definition (1-2 sentences):

Etiologies: What causes this pathology?

Asterisk (*) those specific to this patient.

List Meds used to manage this primary

pathology. Asterisk (*) those specific to

this patient.

Diagram and discuss the Pathophysiology of

the primary Medical Dx of the patient.

Signs & Symptoms: Asterisk (*)

those that are present in this patient.

List diagnostic tests used to manage

this pathology: Asterisk (*) those that

are actual in the patient.

Include APA Reference List and in-text citations.

Patho Map

2

Initial Assessment Data r/t Priority Nsg Dx:

Highest Priority Nursing Dx:

Plan: S/T Goal:

Interventions:

Rationale for Nsg Dx #1 (number items to correspond

with interventions; cite/quote references and page

numbers):

Evaluation::

Skills Used for this Nsg Dx:

Explore potential Legal/Ethical Issues r/t caring for patient:

Patho Map

3

Use back of page as necessary for all sections.

Initial Assessment Data for 2nd Highest Nsg Dx:

Nsg Dx #2:

Plan: S/T Goal:

Interventions: Cite reference with item.

Rationale for Nsg Dx #2 (number items to correspond

with interventions; cite/quote references and page

numbers):

Evaluation:

Skills Used for this Nsg Dx:

Safety Concerns when caring for this patient:

APA Reference List on back of page:

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Date Progress Notes