Student's Name Date

NURSING HISTORY
Client's Initials: C.G. Informant: _Chart !atient staff__
"#e: $$ Se%: _&_
"dmittin# Dia#nosis: Lower Extremity Cellulitis
"ller#ies: NKMA
Chocolate (diarrhea), walnuts (GI uset)
Chief Com!laint: !lceration o" le#s disallows wal$in#
Histor' of !resent illness: %%&year&old male with 'eriheral (ascular
)isease came in with le# edema* 't had ulcerations o" lower extremities
which le"t him una+le to wal$, came "rom home*
(atho!h'siolo#':
Cellulitis: a common, otentially serious +acterial s$in in"ection* -$in on
lower le#s is most commonly a""ected, thou#h cellulitis can occur
anywhere on your +ody or "ace* It may a""ect only your s$in.s sur"ace, or
it may also a""ect tissues underlyin# your s$in and can sread to your
lymh nodes and +loodstream (Mayoclinic*com)*
Le"t untreated, the sreadin# in"ection may raidly turn li"e&threatenin#*
/hat.s why it.s imortant to see$ immediate medical attention i" cellulitis
symtoms occur*
(ast medi)al and sur#i)al histor': '(), A0i+, hyertension, 1'2,
3enous stasis dermatitis, 3enous stasis ulcer, le# edema
(HYSIC"* "SS+SS&+NT
,ital Si#ns: T -$.$ a%illar' ( ./ radial 0oundin# R 12
(ain .342 in arm and le# O1 sat -.5 room air
63( 45%677 (automated lyin#7
General "!!earan)e: 'atient loo$s #ood "or his a#e, seems lethar#ic
S8in: 8 cal" stasis ulcer with san#uineous draina#e, redness and
hyer i#mentation to le"t extremities, Le#s warm +ilaterally, arms
mildly cool +ilaterally, le"t le# /E) stoc$in#, 8 an$le dressin#, no
edema, sta#e II le"t +uttoc$s ulcer
Cardio9as)ular: Caillary re"ill 9 seconds +ilaterally, chart said t had
irre#ular rhythm +ut sounded normal uon auscultation, 95# +ilumen
I( on "orearm inserted 9647647, "lushed with :ml normal saline, (enus
dulex ne#ati3e "or clots, EKG and E0 normal (::&;:<)
Res!irator': 8oom air* No ad3entitious lun# sounds +ilaterally*
Gastrointestinal: 1owel sounds resent in all "our =uadrants, no
+ruits auscultated, a+domen "lat and so"t, had a 1M >this mornin#?, low
sodium diet, ate +rea$"ast, low '@ inta$e due to sel"&care de"icit
Genitourinar': 4; 0 0oley, clear yellow urine, lanned to +e remo3ed
on 969:647
Neurolo#i)al: No num+ness noted
&ental Status +%am: 'atient AA@xA

&us)ulos8eletal: Lower extremity wea$ness, $yhosis, thin "ramed,
una+le to am+ulate
4
&edi)ations :Generi) 6rand ")tions Dose Side +ffe)ts
; Nursin# Im!li)ations7 <h' is Client on this &edi)ation
)ocusate (Colase)&455m# /I) '@* Gi3en to re3ent
constiation in atients who should a3oid strainin#* /his dru#
romotes incororation o" water into stool, resultin# in so"ter
"ecal mass* -ide e""ects include throat irritation, +itter taste,
mild crams, and rashes* )o not administer within 9 hr o" other
laxati3es* ()a3isBs )ru# Guide, 7;;) 'atient is on dru# to a3oid
strainin#, which could cause +leedin#*
Asirin& %4m# daily '@* Gi3en to roduce anal#esia and
reduce in"lammation and "e3er +y inhi+itin# the roduction o"
rosta#landins* Also decreases latelet a##re#ation and
decreases incidences o" transient ischemic attac$s and MI*
-ide e""ects include tinnitus, GI +leedin#, dysesia, ei#astric
distress, nausea, a+dominal ain, anorexia, heatotoxicity,
3omitin#, ex"oliati3e dermatitis, -te3ens&Cohnson syndrome,
toxic eidermal necrolesi, anemia, hemolysis and aller#ic
reaction ()a3is )ru# Guide, 44A4)* 'atient is on this
medication to reduce ain and in"lammation*
2earin& :,555 units -C =49h* A +lood thinner, 2earin
re3ents clots in the +lood 3essels* (National Li+rary o"
Medicine)* 'atient is on this dru# due to history o" A"i+, and
on#oin# immo+ility, to re3ent clots*
Atenolol (/enormin)& 9:m# '@ =49h* /his is a +eta&+loc$er is
used "or an#ina or to lower +lood ressure* -ide e""ects include
orthostatic hyotension and diDDiness (National Li+rary o"
Medicine)* 'atient is on this dru# due to history o" 2/N*
S!ee)h: 'atient is 3er+al
&ood3"ffe)t: 'atient is calm and cooerati3e, t #ets ain at ni#ht in
L le# and arm, relie3ed with ain meds*
Sensorium and Co#nition: 'atient aware o" surroundin#s
+ri8son's "dult Sta#e of De9elo!ment: Maturity (;: to death)& E#o
Inte#rity 3s* desair: @lder adults need to loo$ +ac$ on li"e and "eel a
sense o" "ul"illment* -uccess at this sta#e leads to "eelin#s o" wisdom,
while "ailure results in re#ret and +itterness ('sycholo#y*a+out*com)*
Identif' Client=s Con)erns Re#ardin#: hos!itali>ation
'atient is aware he needs hel er"ormin# A)LBs due to his condition*
9
Lisinoril ('rini3il)& 45 m# daily '@* It treats hi#h +lood
ressure and heart "ailure, reducin# the ris$ o" stro$e and heart
attac$* -ide e""ects include dry cou#h and headache* (National
Li+rary o" Medicine)* 'atient is on this medication due to
history o" 2/N*
0urosemide (Lasix)& 95 m# daily '@* A diuretic, it reduces "luid
retention and hi#h +lood ressure* -ide e""ects include
hyotension, anorexia, dehydration, and dry mouth (National
Li+rary o" Medicine)* 'atient is on this medication due to
edema and 2/N*
/amsulosin (0lomax)& 4*7m# tid '@* /his alha&+loc$er treats
ro+lems with urination caused +y an enlar#ed rostate, such
as +eni#n rostatic hyerlasia* -ide e""ects include swellin# o"
the "ace or hands, tin#lin#, syncoe, ro+lems eEaculatin#, and
a ain"ul rolon#ed erection not caused +y sexual arousal
(National Li+rary o" Medicine)* 'atient is on this medication due
to his a#e and #ender*
-il3er -ultadiaDine (external)& a toical antimicro+ial dru#, this
is rescri+ed "or the re3ention and treatment o" wound sesis*
-ide e""ects include "e3er, chills, +ody aches, "lu&li$e
symtoms, +leedin#, Eaundice, dar$ urine, hematouria,
olyuria, oli#uria, drowsiness and con"usion (8xList*com)*
'atient is on this dru# "or the re3ention o" sesis in his
wounds*
A
*a0 and Dia#nosti) Tests :in)lude results of !ertinent
tests for 'our )lient. Dis)uss ho? these tests and results
!ertain s!e)ifi)all' to 'our )lient=s )ondition.
R6C@1.$$ "0normal Normal@/..@..-&I*3u*
<6C@$.2 Normal Normal@/.$@42.$83u*
H#0@-.4 "0normal Normal@4/@4A./#3d*
Hemato)rit@1$.2 "0normal Normal@/4..@.2./5
Glu)@-Bm#3d* Normal Normal@A2@44.m#3d*
Creatinine@4.1m#3d* Normal Normal@2..@4..m#3d*
Na@4/.m+C3* Normal Normal@4B.@4/.m+C3*
D@/.43* Normal Normal@B..@..2m+C3*
Ureanitro#en@.4m#3d* Normal Normal@$@1Em#3d*
Ca@$.1m#3d* "0normal Normal@$..@42..m+C3*
(latelets@4A4.2 Normal Normal@4.2@/2283u*
GFR .Aml3min "0normal Normal@ GE2ml3min
C(D /1Eu3* "0normal Normal@12@122u3*
*a0 tests sho? that the R6C hemo#lo0in and hemato)rit
le9els are lo?H this is due to !atient=s anti)oa#ulant
thera!'. +le9ated C(D le9els )ould indi)ate inIur' or
stress to mus)le tissue the heart or 0rainH it )ould also
indi)ate renal failure :&edline (lus7. +le9ated GFR )ould
indi)ate dama#ed 8idne's from HTN.
Nursin# Dia#noses *ist in (riorit' Order
:*ist all nursin# dia#noses that a!!l' to 'our )lient in
!riorit' order and indi)ate ?hether ea)h dia#nosis
?as )lient nurse or mutuall' deri9ed7.
")ute !ain related to irritation of the s8in im!aired
s8in inte#rit' and is)hemi) tissue as e9iden)e 0'
!atient re!ortin# !ain as .342 in arm and le#s. :Student
nurse deri9ed7
Im!aired s8in inte#rit' related immo0ilit' as e9iden)e
0' the !resen)e of ul)ers of the lo?er e%tremities and
on the 0utto)8s. :Student@nurse deri9ed7
Ris8 for im0alan)ed nutrition@less than 0od'
reCuirements related to !oor inta8e. :&utuall'
deri9ed7
Ris8 for )onsti!ation related to sedentar' lifest'le.
:&utuall' deri9ed7
7
NURSING DI"GNOSIS: ")ute !ain related to irritation of the s8in im!aired s8in inte#rit' and is)hemi) tissue as
e9iden)e 0' !atient re!ortin# !ain as .342 in arm and le#s.
Su0Ie)ti9e Data that
su!!orts the nursin#
dia#nosis:
'atient stated he had
arm and le# ain,
relie3ed +y rest*
O0Ie)ti9e Data that
su!!orts the nursin#
dia#nosis:
'atient reorted ain
in arm and le# as
:645*
'atent has cellulitis
Client Out)omes
'atient will
3er+aliDe reduced
ain le3el*
'atient will ha3e
increased com"ort*
Nursin# Inter9entions

At "re=uent inter3als,
assess atientBs ain
le3el usin# scale o" 4
to 45*
Assess the =uality,
location, duration,
se3erity, onset, and
reciitatin# "actors o"
the ain*
@""er ain medication
as indicated +y
assessment, accordin#
to ro3iderBs order*
2a3e atient select
nonharmacolo#ical
inter3entions that ha3e
relie3ed ain in the
ast ('otter F 'erry,
GH;)*
Create a com"orta+le
en3ironment +y
adEustin# li#htin# and
temerature*
Rationale
'ain is su+Eecti3e, it
is what the atient
says it is (Nursin#
Iorld*or#)*
Assessment o" ain
is a critical ste to
ro3idin# #ood ain
mana#ement
(A28J*#o3)*
'ro3ides atient with
ain relie", allowin#
"or #reater mo+ility
and com"ort ('otter F
'erry, 44G7)*
Nonharmacolo#ical
aroaches hel
atients imro3e
=uality o" li"e and
decrease anxiety and
deression, without
the threat o"
addiction ('otter F
'erry, GH;)*
A com"orta+le
atmoshere
romotes relaxation
(A28J*#o3)*
+9aluation
'er"orm on#oin# e3aluations o"
inter3entions ('otter F 'erry,
G%4)
8eassess atientBs ain and
le3el o" com"ort, "ocusin# on the
chan#in# character o" ain and
the atientBs ercetions o" the
e""ecti3eness o" a theray
('otter F 'erry, GGA)*
Monitor "or side e""ects o" ain
medications ('otter F 'erry,
H4%)*
:
NURSING DI"GNOSIS: Im!aired s8in inte#rit' related im!aired am0ulator' fun)tion as e9iden)e 0' the !resen)e
of ul)ers on the lo?er e%tremities and on the 0utto)8s.
;
Su0Ie)ti9e Data
that su!!orts the
nursin#
dia#nosis:
'atient stated he
was immo+ile and
needed hel with
A)Ls
O0Ie)ti9e Data
that su!!orts the
nursin#
dia#nosis:
'atient has low
extremity wea$ness
-ta#e II +uttoc$s
ulcer resent
Client Out)omes
'atient will not
ha3e "urther s$in
+rea$down*
'atient will
reosition more
"re=uently*
'atientBs existin#
ulcers will heal*
2ematocrit and
hemo#lo+in le3els
will +e within
normal ran#e*
Nursin# Inter9entions

Assess s$in "rom head to
toe, notin# any chan#es or
a+normalities*
Kee s$in clean and dry*
Aly dressin# accordin# to
wound care ro3iderBs
order*
Encoura#e atient to
reosition or shi"t at least
e3ery 9 hours*
Ele3ate head o" +ed no
more than A5 de#rees*
Rationale
Notice o" chan#es or
a+normalities o" the s$in is the
"irst ste to ressure ulcer
re3ention (A28J*#o3)*
Moisture so"tens s$in and causes
a +rea$ in s$in inte#rity ('otter F
'erry, 44G7)*
'ro3ides aroriate toical
theray to wound ('otter F 'erry,
44G7)*
8eositionin# remo3es ressure
('otter F 'erry, 44G7)*
/he hi#her the head o" the +ed is
ele3ated, the more li$ely
shearin# "orces are resent
('otter F 'erry, 44G7)*
+9aluation
8eassess atientBs
s$in inte#rity "rom
head to toe*
8eassess atientBs
a+ility to am+ulate
and er"orm A)LBs*
Monitor existin#
wounds "or healin#*
H
Dis)har#e (lan:
(re9ious )ommunit' resour)es:
'atient was not re3iously a art o" any community
resources*
Communit' resour)es needed for this dis)har#e:
(h'si)ian for monitorin# )ellulitis HTN )ir)ulation
!erfusion and earl' dete)tion of )lots.
Dietitian to aid in de9elo!in# diet ?ith lo? sodium
:Car!enito@&o'et /-B7.
(h'si)al thera!ist to aid in rea)hin# the hi#hest le9el of
self@)are.
Nurse to fa)ilitate ?ound )are.
Dis)har#e tea)hin# !lan:
Tea)h !atient im!ortan)e of !erformin# a)ti9ities as
tolerated.
Tea)h !atient to shift ?ei#ht to minimi>e sa)ral ul)ers.
Tea)h !atient earl' si#ns for )lots in)ludin#
dis)oloration of the s8in and diminished !ulses.
Tea)h !atient to follo? a diet lo? in sodium to de)rease
edema.
Theoreti)al Frame?or8 ?hi)h #uided the nursin#
inter9entions :in)luded dis)ussion of the dimension of
intera)tion and other theoreti)al )on)e!ts that 'ou
ha9e used7
Ro'=s "da!tation &odel@ This model !romotes
ada!tation of illness that )annot 0e )uredH it allo?s a
theor'@0ased nursin# inter9ention from a holisti)
nursin# !ers!e)ti9e.
Resear)h To!i):
Cellulitis: Ho? this effe)ts lifest'les
D,T: Ho? to redu)e )han)es of de9elo!in#
D,T: Ho? to re)o#ni>e the earliest of si#ns
Refle)tion:
This !atient ?as e%tremel' !leasant to ?or8 ?ithH I
)onne)ted ?ith him ?ell and sin)e he ?as a0le to
)ommuni)ate ?ith me

Ior$s Cited
Carpenito-Moyet, Lynda J. (2010). Handbook of Nursing iagnosis. !"i#ade#p"ia, !$% Lynda Jua## Carpenito-Moyet.
eg#in, Judit" H., et a#. (2011). Daviss Drug Guide for Nurses. !"i#ade#p"ia, !$% &.$. a'is Co(pany.
htt:66sycholo#y*a+out*com6li+rary6+lKsychosocialKsummary*htm
htt:66la+testsonline*or#
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"ttp%))***.n#(.ni".go')(ed#inep#us)en+y)arti+#e)004504."t(
"ttp%))***.(ayo+#ini+.org)diseases-+onditions)+e##u#itis)basi+s)definition)+on-20024671
"ttp%))***.r8#ist.+o()si#'adene-drug)indi+ations-dosage."t(