Create Concept Map and a Care Plan for impaired skin. Patient Introduction: Location: Skilled Nursing Home...

Client Initials: Mrs.Morrow

Age: 80 years Gender:Female Room Admit Date : Three days back

CODE Status N/A Allergies:N/A

Diet : Regular diet

Activity: Needs extensive assistance

Braden Score : 16 at medium risk for pressure ulcer

Admitting Diagnoses/Chief Complaint: Venous stasis ulcer on her right medial malleolus

Assessment Data:

Chief complaints: Presence of Venous stasis ulcer in her leg

Present illness history : Mrs.Morrow is alert and oriented but forgets some recent events.She has unsteady gait ,so she needs extensive assistance while performing activities of daily living and she is easily fatigued. Braden Scale score is 16 which indicates she is at risk for pressure ulcer and her skin is intact except for the venous stasis ulcer on the right medial malleolus. She has brown hyperpigmentation on both lower legs with +2 edema.

Surgical history: N/A

Medical history:  Her past medical history is she has chronic obstructive pulmonary disease (COPD), chronic venous insufficiency, and deep vein thrombosis (DVT). Peripheral arterial disease is ruled out by duplex ultrasound.Now admitted due to presence of venous stasis ulcer in right leg and requiring wound dressing. She needs assistance to carry out activities of daily living.Pain may be present in legs so kept elevated for improving circulation.

Family history: N/A

General - Not acute distress

Eyes - PERRLA

ENT - No discharge or abnormalities

Neck - No lymph node enlargement

Lymph Nodes - No lymphadenopathy

Cardiovascular - No chest pain, no palpitation, no shortness of breath ,but signs of fluid overload present

Lungs - Clear to auscltation,wheezes present.

Skin - No rashes, skin warm ,dry. Skin in legs is cool and has brown hyperpigmentation on both lower legs with +2 edema and venous stasis ulcer present in right medial malleolus.

Abdomen - Normal bowel sounds

Genito Urinary – No complaints but needs assistance for toiletting .

Rectal – Needs assistance for going to bathroom

Extremities - Slight indentation edema present in lower legs. Peripheral pulses feeble and hypepigmentation is seen in lower legs with ulcer in right leg. Needs assistance for walking .Antiembolism stocking applied in left leg

Musculo Skeletal - 3/5 strength, weakness and unsteady gait.

Neurological – Alert and oriented x 3 patient is alert and oriented to person, place, situation.

Vital signs: Normal but tachypnoea may be present

Medications:Tab. Aspirin 81mg PO ,Albuterol inhaler 300mcg, Zinc vitamin supplement, Acetaminophen 650mg PRN.

Antiembolism stocking in left leg and dressing foe wound in right leg.

Lab Values/Diagnostic Test Results:

Serum electrolytes:

Na+ 142; K +3.9,HCO3-28, Cl 102.

May be due to COPD she is at chronic respiratory acidosis.

Treatments:

Application of anti embolism stockings, dressing for wound and application of hydro colloid dressing over wound. Elevation of both extremities. Normal diet with nutritional supplements.Local wound management supported by formulary and clinical expertise.Management of surrounding skin to reduce further deterioration.

Primary Nursing Diagnosis:

• Ineffective peripheral tissue perfusion related to compromised circulation as evidenced by presence of brown pigmentation in legs, and edema.
• Activity intolerance related to weakness in limbs as evidenced by her necessity of assistance to carry out activities of daily living due to old age
• Fatigue related to old age as evidenced by her activities  inability to maintain usual routines
• Risk for impaired skin integrity related to venous ulcer as evidenced by brown pigmentation in skin and braden scale score of 16.