Kristen Nii-Jensen

NURS 360
Concept Map
6. Deficient knowledge: Nature of and
management regimen of hypertension and
diabetes

Pt reports needing more information

concerning diabetes/cardiac diet
Pt unable to verbalize medication upon
admission
Hx of non-med compliance for
hypertension, hyperlipidemia, and
diabetic medication
Requests bacon and spam for meals
despite being on cardiac/diabetes diet
Deficient knowledge of influence of salt
on cardiac function
Consumes sweet bread between meals

1. Infection/Skin integrity
WBC 15.2
Myelitis and fasciitis to lateralis muscle
in right thigh- CT scan confirming
infection worsening
Post-op for abscess to clavicle
Wound vacuum/dressing/
MRSA confirmed to abscess wound
IV daptomycin currently admin
Prior hx of MRSA infection to r thigh

Infect:
Fluid:
Pain:
BG:
Perf:
DK:

2. Altered fluid & electrolyte imbalance

Chief Medical Diagnosis:

Left clavicle abscess removal/ Post-OP

Priority assessment: Pain, s/s infection, wound
healing/site, drainage/wound vacuum
settings/dressing, I&O, impaired mobility

5. Risk for Ineffective tissue perfusion

Thickened, brown/yellow toe nail

beds
Dry, thick, darken skin to lower
extremities
anemia
Reports of occasional numbness and
paresthesia to toes (Chronic)
Pt report of legs feeling cold
Ineffective wound healing
Pt prescribed lovenox subq
injections

NA: 135 (Low-normal)

K+: 3.7 (Low-normal)
Cl-:99 (Low-normal)
Wound vacuum intermittent
sanguineous drainage (20ml 8-hour
shift)
PICC line to R brachial
Dry skin

3. Pain
4. Risk for Unstable blood glucose levels

Blood glucose levels consistently >150

Frequent use of sliding scale titrated rapid-acting
insulin (Novalog) subQ
Routine Humalog 30 w/ meals/20 units HS(75%/
25%) subQ
Reports eating sweet bread between meals
Hx of non-medication compliance
Obesity BMI 36.5

Surgical wound- Clavicle abscess

Acute myelitis and fasciitis to
lateralis muscle in r upper thigh
Use of pain medication
(ibuprofen/oxycodone)
Report of pain