Leeah Javier Concept Map/N360/04-07-14 Queens/Ewa8 Infection:

Assessment: left foot swelling and erythema. Noted purulent drainage from small opening at plantar aspect, weak pedal pulse. Reported chills; Gram stain test result: + 1 staph aureus, +1 beta hemolytic strep group A; 2+WBC. Neutrophil 84.7 (H), MRSA infection. Possible infectious fasciitis Contact Isolation Tx: doxycline, clindamycin Pain Patient describes sharp, throbbing pain on left great toe, rates pain12/10, radiating to lower left extremity Tx: Fentanyl citrate injection Scheduled pain meds Tramadol q6h, Dilaudid, Tylenol; elevated affected extremity with pillows

Impaired Tissue Integrity

Abscess of great toe of left foot; Xray foot complete 3views noted soft tissue edema of the great toe; ulceration on plantar surface of left great toe. Decrease sensation Tx: application of wound vac; skin graft from left thigh to left foot. Dilaudid for pain

Chief Medical Diagnosis: Diabetic Infection of the Left Foot Priority Assessment: Pain, Infection, Blood glucose level, Wound, Psychosocial, Mobility Risk for Unstable Blood Glucose Level Patient has history of DM2 untreated, uncontrolled; 2years ago she stopped seeing any physician; off on insulin no medications on file; Mother is also diabetic; Smokes 3-4 cigarettes daily; A1C: 12.5; Average BGlevel: 280; Urinalysis: 3+ glucose; ketones > 80 (H) Tx: Accu check; Novolog Flexpen with meals; Lantus 14units hs.

Anxiety:
Patient is aware of her condition and possible complications; expressed concern over her two young kids, mobilization, marriage in on the rocks, unemployed and no other support system except mother in law, sleep deprivation Social work counseling, transportation arrangement, PT consult Meds: Midazolam and Melatonin for comfort

Impaired Physical Mobility

Left foot wound pain worsens when ambulating; Fall precaution Wt.210lbs; BMI 34 (H) Ambulate with assist; steady gait; tolerated ROM, reposition