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

Mdx: Cellulitis, Right leg

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

NDx #2: Risk for infection related to invasive procedure.

Patients Initials: C.D. Age: 48 years old Gender: Male

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 Assess general health condition. Monitor vital signs every 4 hours. Assist in administering antibiotics Rationale To have a baseline data Expected Outcome 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 120mmHg

To prevent edema, ineffective tissue perfusion To promote good circulation

Elevate the affected leg with 2 pillows

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 Monitor vital signs every four hours. note any changes especially temperature.
Review CBC results

Rationale To establish a baseline data

Expected Outcome Patient will have no occurrence of secondary infections.

To establish baseline data and to note if there's infection To prevent the spread of infection

Observe medical aseptic technique when performing nursing procedures.

Monitor and maintain in antibiotic therapy at prescribed flow rate. Assist in pre-operation of split-thickened skin grafting (R. leg)

To prevent infections

To help in the curing of the client's cellulitis