Cellulitis, Right leg CONCEPT MAP
NDx #1: Risk for ineffective tissue
perfusion related to edema.
Subjective Cues: (12-20-2013)
there's secretions coming out of
the CURAVAC, and it can or may
cause ineffective tissue perfusion
in the future
Patients Initials: C.D.
Age: 48 years old Gender: Male
Mdx: Cellulitis, Right leg NDx #2: Risk for infection related to
invasive procedure.
Patient
48 y.o, male
Admitting Diagnosis
Cellulitis
Objective data
Temp=36.5, RR=19, Pulse=78, BP= 120/80
good capillary refill in 1-2 secs, skin is warm to
touch, no redness and swelling in the affected part
Subjective data
patient says no tingling or numbness in the
affected part
Needs assistance in moving
voiding freely
Medical Diagnosis: Cellulitis, Right leg
Basis for Prioritization: Student Nurse: Estrella, Bien G.
Nursing Diagnosis #1: Risk for ineffective tissue perfusion related to edema.

Goal: to maintain adequate tissue perfusion.

Expected Outcome: adequate tissue perfusion

Interventions Rationale Expected Outcome

Assess general health condition.
Monitor vital signs every 4 hours.
Assist in administering antibiotics
To have a baseline data Adequate tissue perfusion. No numbness, no
redness, skin is warm to touch, rapid capillary refill
in the affected leg.
To promote healing,
prevent infection

Maintain CURAVAC pressure at To prevent edema,

120mmHg ineffective tissue
perfusion

Elevate the affected leg with 2 To promote good

pillows circulation

Perform circulatory assessment in To check for tissue

the affected leg. perfusion.

To replace lost fluids

Maintain systemic hydration
Nursing Diagnosis #02: : Risk for secondary infection related to invasive procedure

Goal: to prevent secondary infections

Expected Outcome: patient will have no secondary infections

Interventions Rationale Expected Outcome

Monitor vital signs every four hours. note To establish a baseline data Patient will have no occurrence
any changes especially temperature. of secondary infections.

Review CBC results To establish baseline data and

to note if there's infection

To prevent the spread of

Observe medical aseptic technique when infection
performing nursing procedures.

Monitor and maintain in antibiotic therapy at To prevent infections

prescribed flow rate.

Assist in pre-operation of split-thickened skin To help in the curing of the

grafting (R. leg) client's cellulitis