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This Concept Map, created with IHMC CmapTools, has information related to: graded 3, V. Expected Outcomes 1. The patient will have no further infection by the time of discharge. 2. The patient will not have to have another I&D to remove infected tissue during lifetime. 3. The patient will be able to regulate blood sugar by the time of discharge. 4. The patient will be able to comprehend me by eye blinking by the end of my shift. 5. The patient will be able to have his pain controlled by the time of discharge. 6. The patient will show a decrease in MRSA infection by the time of discharge. 7. The patient will show a decrease in all around infection by the decrease of Abx by the time of discharge. 8. The patient will not develop anymore infection by the time of discharge. ???? Interdisciplinary/Interventions 1. The nurse will help to reduce pain. Rationale: To make the patient comfortable and make the healing process easier for the patient. 2. The nurse will change dressing per MD order Rationale: To promote sterile healing. 3. The nurse will monitor blood glucose carefully Rationale: To try and regulate as much as possible 4. The nurse will administer abx Rationale: To redcue infection 5. The nurse will turn and reposition q 2 hour Rationale: To help heal skin tears 6. The nurse will support RLE Rationale: To reduce pain of RBKA 7. The nurse will provide O2 through trach with humidifier. Rationale: To thin secretions and provide oxygen therapy. 8. The nurse will provide oral care q 4 hours Rationale: To decrease the risk of infection. (Lemone & Bourke 2008), I. Patient Info & Medical Diagnosis T.S 55 y.o. white male RBKA, MRSA, Myocardial infarction, CVA, anoxic brain injury, diabetes, tracheostomy, cerebral aneurysm, sleep apnea, respiratory failure, morbid obesity. affects II. Pathophysiology of an amputation 1. Amputatation results from interruption of blood flow 2. When the blood flow is interrupted the tissue becomes ischemic and can become infected especially in a patient with diabetes. 3.In chronic disease processes, circulation is impaired, venous pooling begins and edema develops. 4. Stasis ulcers develop and become infected because impaired healing and altered immune processes allow bacteria to proliferate, leading to gangrene 5. Risk factors include hypertension, diabetes, smoking, hyperlipidemia (Lemone & Burke 2008), V. Expected Outcomes 1. The patient will have no further infection by the time of discharge. 2. The patient will not have to have another I&D to remove infected tissue during lifetime. 3. The patient will be able to regulate blood sugar by the time of discharge. 4. The patient will be able to comprehend me by eye blinking by the end of my shift. 5. The patient will be able to have his pain controlled by the time of discharge. 6. The patient will show a decrease in MRSA infection by the time of discharge. 7. The patient will show a decrease in all around infection by the decrease of Abx by the time of discharge. 8. The patient will not develop anymore infection by the time of discharge. ???? Evaluation of Expected Outcomes 1. The infection was not able to be evaluated today. Goal not met. 2. The goal is not in a time frame to be evaluated today. Goal unable to be evaluated. 3. The patient's blood sugar decreased from 231 to 191. Goal met. 4. The patient was still unable to respond to me with verbal cues, would react to pain stimuli. Goal not met. 5. The patient's pain was not able to be evaluated today. By the end of my shift, patient was still in recovery. Goal not able to be evaluated. 6. The MRSA was not able to be evaluated for decrease by the end of my shift. Goal not met. 7. Goal not able to be evaluated today., IV. Priority Nursing Diagnosis Skin Integrity, Impaired (Wilkinson & Ahern 2009) prioritizes IV. Other Nursing Diagnosis 1.Gas Excahnge, Impaired r/t excess secretions aeb crackles during auscultation. 2. Blood Glucose, Risk for Unstable r/t chronic diabetes aeb BS of 191-231 3. Pain, Chronic r/t stump pain aeb redness 4. Urinary incontinenece r/t impaired mental status aeb catheter 5. Infection, Risk For r/t RBKA, tracheostomy, and skin tears 6. Bowel Incontinence r/t impaired mental status aeb brief 7. Self-Care Deficit r/t impaired mental status aeb quality of skin and lack of oral care. (Wilkinson & Ahern 2009), IV. Priority Nursing Diagnosis Skin Integrity, Impaired (Wilkinson & Ahern 2009) Expected Outcomes V. Expected Outcomes 1. The patient will have no further infection by the time of discharge. 2. The patient will not have to have another I&D to remove infected tissue during lifetime. 3. The patient will be able to regulate blood sugar by the time of discharge. 4. The patient will be able to comprehend me by eye blinking by the end of my shift. 5. The patient will be able to have his pain controlled by the time of discharge. 6. The patient will show a decrease in MRSA infection by the time of discharge. 7. The patient will show a decrease in all around infection by the decrease of Abx by the time of discharge. 8. The patient will not develop anymore infection by the time of discharge., II. Pathophysiology of an amputation 1. Amputatation results from interruption of blood flow 2. When the blood flow is interrupted the tissue becomes ischemic and can become infected especially in a patient with diabetes. 3.In chronic disease processes, circulation is impaired, venous pooling begins and edema develops. 4. Stasis ulcers develop and become infected because impaired healing and altered immune processes allow bacteria to proliferate, leading to gangrene 5. Risk factors include hypertension, diabetes, smoking, hyperlipidemia (Lemone & Burke 2008) leads to III. Focused Data Assessment 1.Right leg was red near area of amputation 2. Patient would twitch with pain when I would move the stump to reposition 3. Vitals 128/72, pulse 95 T 98.3 (A) R 15 (V) and O2 99% 4. Dressing to stump was moistened with blood. 5. Blood sugar 191-231 throughout day 6. Wound on end of stump was necrotic, black, infected, and oozing. 7. Surgeoun removed the necrotic tissue and cleaned out inside of wound 8. Wound was left packed with wet dressing and wrapped with kerlex.