Nursing Care of the Older Adult
Module 05 Assignment - Case Study Concept Map and Plan of Care
Case Study Concept Map
Angela Moody
Rasmussen College
NUR2214 Nursing Care of the Older Adult
Dr. Karen Thorton
November 10, 2019 Nursing Care of the Older Adult
Module 05 Assignment - Case Study Concept Map and Plan of Care
Concept Map:
Nursing Plan of Care Primary Medical Diagnosis:
Infected diabetic ulcer on left legPrioritized Nursing Dx# 2 Risk for falls r/t moderate functional issues & fatiguePrioritized Nursing Dx# 6 Ineffective health maintenance r/t moderate functional issues & fatigue
Prioritized Nursing Dx# 5 Activity intolerance r/t moderate functional issues & fatiguePrioritized Nursing Dx# 3 Ineffective peripheral tissue perfusion r/t impaired arterial circulation & ulcerPrioritized Nursing Dx# 1 Impaired tissue integrity r/t impaired metabolic state
Prioritized Nursing Dx# 4 Impaired physical mobility r/t moderate functional issues & fatigue Nursing Care of the Older Adult
Module 05 Assignment - Case Study Concept Map and Plan of Care
Prioritized Nursing Diagnoses Goal Nursing Interventions
Impaired tissue integrity r/t impaired metabolic stateTissue integrity: skin & mucous membrane
Wound decreases in size & has increased granulation tissue
Specific: The goal is to improve skin integrity, repair damaged tissue, & treat infected wound on leg. The goal is critical in the plan of care because it can lead to infection spreading throughout the body, necrosis or amputation of the leg if left untreated. The nurse & the interprofessional health care team are involved in the complete plan of care for this patient, including a wound care nurse, primary physician, endocrinologist, dietitian, physical therapist, etc. Resources such as wound care supplies are provided by the healthcare facility and online resources are available for patients with diabetes. Measurable: Progress is tracked & measured by inspecting, measuring, & documenting the wound on the leg every shift (Q12HR). This is to determine if the wound is healing & shrinking with increased granulation tissue or if no improvements or worsening of the condition is taking place. Accomplishment of this goal will be determined when the wound if fully healed. Achievable: This is a realistic & achievable goal as long as the patient and healthcare Monitor site at least once daily for changes
Provide tissue care PRN
Keep sterile dressing technique during care
Administer antibiotics as ordered
Instruct client to avoid rubbing or scratching wound
Premedicate for dressing changes PRN
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