CSU, STANISLAUS B.S.N.
CLINICAL PLAN OF CARE
Student:
Priti Patel
Date of Care:
March 4, 2013
Room Number:
205-1
Patient Data
Admitting Diagnosis
Bilateral Lower leg extremities cellulitis
Age
59
Spiritual Focus
Christian
Culture
Asian
Patient Initials
B-L
Gender
Female
Height
62 inches
Weight
93.4 kg
Admitting Date
March 4, 2013
Vital Signs
T
127/65
P
70
R
16
B/P
127/65
O2Sat
100% Room Air
Past Medical History
Obesity, type 1 diabetes, chronic kidney disease stage 3, mental delay, hypertension, hyperlipidemia
Surgical History
Umbilical hernia repair in March 2012
Pain Scale
None
Diet:
Activity:
Full ambulatory –moderate fall rick
Foley:
Diabetic and Cardiac
1800 Kcal
None
NG/Feeding Tube:
None
Advance Directives:
Not in chart
Code Status:
Full
VS Freq:
q 4 hours
TEDs/SCDs:
None
PCA/Epidural:
None
Telemetry:
Was on tele but was
discontinued per doctor’s
orders on 03/05/2013
Vascular Access:
IV Site:
Drains/
Tubes:
Glucose
Monitoring:
None
Yes
Safety Considerations:
Peripheral IV. Right Hand. Normal saline.
Rate 200ml/hr-Patient considered moderate fall risk.
IV Solution: 0.9% Normal Saline Lock.
Dressing Changes:
Bilateral extremeties. Change BID. Xeroforms.
Labs to be Drawn:
CBC, Chem 7 and CT scan
Scheduled Procedures:
None
Notes on Pathophysiology:
Cellulitis is an infection of the soft tissues underneath the skin. It occurs when bacteria invade broken or normal skin and start to
spread. The infection can cause inflammation. People at risk for developing cellulitis include those with trauma to the skin or other
medical problems such as diabetes,or people with a weak immune system. Symptoms include the infected area will be warm, red,
swollen, and tender.
Lab and Diagnostic Test Data
Hematology
WBC
RBC
HgB
Hct
MCV
Date
Date
Range
3/4/2013 3/5/2013
12.6
13.9
3.9
3.31
11.6
10
35
29.5
89.9
89.3
Trend
20.85
41374
3.5-5.5
11.7-15.7
35-46
80-99
High
Low
Low
Low
Normal
Sign of infection. Patient has cellulitis
Patient has chronic stage 3 kidney disease.
Patient has chronic stage 3 kidney disease.
Patient has chronic stage 3 kidney disease.
MCH
MCHC
RDW
Plt Count
29.8
33.1
13.7
357
30.2
33.8
13.6
286
73
17
7
2
1
9.2
2.1
0.9
0.3
0.1
77
15
7
2 0
0 0
10.6
2.1
0.9
0.2
0
Pending
Sodium
Potassium
Chloride
Carbon Dioxide
Anion Gap
BUN
Creatnine
GRF calculation
144
4.5
103
29
12
44
2.72
17.8
144
4
108
25
11
53
1.95
26.2
Glucose
Hemoglobin A1c
Estim Average Glucose
Lactic Acid
Phosphourous
116
6.3
134
0.9
0.5
Nuet %
Lymph %
Mono %
Eos %
Baso %
Seg Neutrophils #
Lymphocytes
Monocytes
Esinophils
Basophils
ESR
CBC
WBC
Normal
11.4-14.6 Normal
150-400 Normal
130-400 Normal
36-66 High
Sign of infection. Patient has cellulitis
Normal
0-10 Normal
Normal
Normal
High
Sign of infection. Patient has cellulitis
Normal
<.7 High
Sign of infection. Patient has cellulitis
Normal
Normal
135-145
3.3-5.0
95-110
24-32
0.5-1.3
90mls/min/1.73m2
Normal
Normal
Normal
Normal
Normal
High
Stage 3 Chronic Kidney Disease
High
Stage 3 Chronic Kidney Disease
Low
Stage 3 Chronic Kidney Disease
63 60-110
5.5-6.2
Normal
High
Type 1 Diabetes
.7-2.1
4.3 2.5-4.5
Normal
Normal
Total Bilirubin
ALT
Alkaline Phosphtase
C-Reactive Protein
Total Serum Protein
Albumin
TSH
Coagulation
Urinalysis
Color
Clarity
Spec. Grav.
Occ. Blood
Ketones
Glucose
Albumin
PH
WBC/HPF
RBC/HPF
Bacteria/casts
X-RAY
CT SCAN
EKG
US
OTHER
Medication Allergies:
27
23
105
4.6
9
4.2
1.45
3/4/2013
Colorless
Clear
1
Negative
Negative
Negative
Negative
6.5
None
None
None
None
.3-1.3
<35
<35
6.0-9.0
3.2 3.5-5
.3-3.4
Pale yellow
Clear
1.002-1.030
0
0
0
0
4.8-7.8
0-2
0-2
0
Normal
Normal
Normal
Normal
Low
Normal
Normal
Normal
Normal
Normal
Normal
Normal
Normal
Normal
Normal
Normal
Normal
Normal
Medications
Generic & Trade Name
Drug Classification
Dose/Route
Frequency
Action of drug and Rationale
(specific to Pt)
Significant Side Effects
Nursing implications related to
patient care & teaching
Amlodipine (Norvasc)
10mg -2 tablets
once daily
Used to treat hypertension.
Hold if systolic BP < 120.
Dizziness, increased heart
rate, swollen feet
Patient should avoid grapefruit
juice while on this med. Monitor
for orthostatic hypertension.
Enoxaprin (Lovenox)
30 MG (0.3 ML
per dose) Sub Q
Patient given to prevent blood
clots.
Dizziness, headache,
insomnia.
Observe injection sites for
hematomas, ecchymosis, or
inflammation.
(Therapeutic
&Pharmacologic)
Should be given by deep SubQ
injection to the left or right
anteriorlateral/posteriorlateral
abdominal wall
Insulin Lispro (Humalog)
Losartan (Cozaar) 50 mg
Tablet
100 unit/mL
per 3 mL TID
6 unit three
tmes daily with
meals
100mg (2
tablets per
dose) once
daily
For type 1 diabetes.
Hypoglycemia, erythema,
swelling site of infection.
Give immediately after each
meal
Hold for systolic BP <120
Diarrhea, dizziness, tired
feeling
If excessive bruising occurs, icecube massage of site before
injection may lessen bruising..
To avoid the loss of drug, do not
expel the air bubble from prefilled
syringes before the injection
Monitor for signs for low blood
sugar. Monitor blood sugars
frequently.
Assess BP (lying, sitting, standing)
and pulse frequently during initial
dose adjustment and periodically
during therapy. Notify health care
professional of significant
changes. Monitor renal function.
May cause ↑ BUN and serum
creatinine
Tell patient to continue taking
medication, even if feeling well.
Instruct patient to take medication
at the same time each day. Caution
Metropolol (Toprol XL)
50mg. 1 tablet
once daily
Used to treat hypertension.
fainting on standing, tired
feeling, dizziness.
Hold if systolic <100, HR<60.
Do not chew or crush.
Tegacycline (Tygicil)
50mg.
IN:dextrose 5%water.
100mls/hour
q12 hour
Normal Saline 0.9%
(1000ml)
100mls/Hr
For treatment of infection due
to cellulitis
Nausea, vomiting, dry
mouth, solemnness. Can
cause suprainfection.
patient to avoid salt substitutes
containing potassium or foods
containing high levels of potassium
or sodium unless directed by health
care professional. Caution patient
to avoid sudden changes in position
to decrease orthostatic
hypotension. Use of alcohol,
standing for long periods,
exercising, and hot weather may
increase orthostatic hypotension.
Take apical pulse before
administering. Monitor bp and bs
frequently. Tell patient to take drug
as directed and to stand slowly to
minimize orthostatic hypotension.
Monitor for and report S&S of
suprainfection . Lab tests: C&S prior
to initiation of therapy; periodic
serum electrolytes, LFTs and kidney
function tests; PT and INT with
concurrent anticoagulant therapy.
Monitor diabetics for loss of
glycemic control
Nursing Diagnoses, Interventions & Outcomes
Chief Medical Diagnosis:
Bilateral lower leg cellulitis
Secondary Diagnosis:
Priority Assessments:
Decreased Mental Capacity
Wound Care
Coping
1.
Nursing Diagnosis:
Impaired verbal communication due to mental delay
Data to Support:
Has mental capacity of child. Patient keeps repeating phrases. Non-cooperative. Does not like to be touched. Will not
let anyone give her injection medications or touch her feet. Patient cannot verbalize pain.
Will gain patient’s trust and patient will do as told. Patient will learn to cooperate and will be willing to have injections
of medication and wound care.
Expected outcome:
Nursing Care:
Use a calm, reassuring approach; explain all
procedures, including sensations likely to be
experienced during the procedure
Explain all activities, procedures, and issues that
involves the patient; use nonmedical terms and
calm, slow speech.Have patience with her and
allow her to have her say. Acknowledge patients
frustrations and concerns. Have patient be more
calm and cooperative. Ask permission before
touching patient. Tell patient what you are going
to do before you do it.
2.
Patient Response and Outcome:
Patient felt comfortable and calmer after her concerns were acknowledged. She was willing to
be touched gave permission to do procedures-give medications, wound culture, wound care.
Nursing Diagnosis:
Impaired skin integrity related to impaired circulation.
Data to Support:
Redness/Swelling of Legs. Shredding of skin. Purulent discharge. Foul odor. WBC 13.9 Patient has hx of diabetes and
hypertension.
Will try to decrease of redness/swelling of legs. Decrease purulent discharge. Absence of foul odor.
Normal WBC count
Expected outcome:
Nursing Care:
Obtain a wound culture. Wound care using topical
and dressing materials ordered, at the prescribed
frequency. Elevate legs to decease swelling. Give
IV antibiotics to get normal wbc count.
Patient Response and Outcome:
There was a decrease in flaking of skin. Swelling and redness of legs was minimized with the
use of topical barrier cream and xeroforms. IV antibiotics were started on the patient.
Blood Report-pending
3.
Nursing Diagnosis:
Ineffective coping
Data to Support:
Patient can be uncooperative when told to take care of her legs. Patient throws tantrum. destructive behavior toward
self or others-Patient became upset and stated walking around the room, pulling her IV, and could have fallen. Patient
has problems discussing her condition
Expected outcome:
Verbalize ability to cope and ask for help when needed.
Remain free of destructive behavior toward self or others
Communicate needs and negotiate with others to meet needs
Use distractors when needed
Nursing Care:
Distracted patient with her favorite things-berret,
tv shows. Calmed patient down when she is being
uncooperative. Used active listening and
acceptance to help the client express emotions
such as sadness and anger (within appropriate
limits). Allowed patient time to relax.
Patient Response and Outcome:
Patient felt calm after her frustrations were of being in the hospital were heard. Patient was
sorry after she tried to pull out IV.
Knowledge
Knowledge:
Educate family members on signs and symptoms of cellulitis or other infections
Educate family members on proper foot care and when dressing needs to be changed
Watch for signs of infection
Inspect feet daily
Wear appropriate footwear
Make sure patient elevates legs to minimize edema
Make sure patient does not stay in the same position for a long time
Discharge/Transfer
Discharge/Transfer:
No purulent drainage or open wound
Normal WBC
Infection control with PO meds
Absence of swelling/edema in feet
No foul odor