Concept Map Essay

623 WordsMar 18, 20153 Pages
Patient Bio-data: Name: A. H. Age: 59, Sex: Male, Race: Caucasian Marital Status: Widower Reason for admission: Infected ankle wound from bed rest. Medical History: Depression, DM Type 2, Infected sacral wound. (A). Psychosocial Assessment Data: * Patient oriented to time, place and person (X3). * Patient is emotionally unstable and exacerbated by the death of wife 6 month ago. * Patient is bed bound, and has not been eating well. NANDA Problem: * Risk for loneliness related to loss of spouse as evidence by patient exacerbation and not eating well Nursing Interventions: * Assist patient with ADL’s including (bathing, dressing and oral hygiene). * Encourage patient to verbalize his feeling and try to engage him in discussion if he wants to and time permit. * Provide patient with nutritional meal, and identify patient favorite diet with patient, * Ensure that patient's chosen diet is rich in protein and other nutrients that will aid wound healing. (B). Physiologic Integrity Assessment Data: * Patient has Diabetic type 2. * Infected wound which developed while on bed rest following an ankle sprain. * Patient need support to ambulate. * Patient has unstable gait and his on fall precaution. NANDA Problem: * Impaired mobility related to unstable gait evidence by patient history of fall and ambulatory support. * Risk for Impaired skin integrity related to decrease mobility. Nursing Interventions: * Make sure infected wound site is clean using aseptic wound care procedure. * Ensure that open wounds are well covered after cleaning. * Ensure patient personal hygiene and oral care is done daily. * Change patient linen and underwear when moist to prevent skin breakdown. * Ensure that patient is constantly repositioned to prevent skin

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