Patho Map
1
Student Name __________________ Clinical Instructor ________________ Date ______________
Unit _________________ Pt Initials _________ Age/Race/Gender ___________
Primary Medical Dx and definition (1-2 sentences):
Etiologies: What causes this pathology?
Asterisk (*) those specific to this patient.
List Meds used to manage this primary
pathology. Asterisk (*) those specific to
this patient.
Diagram and discuss the Pathophysiology of
the primary Medical Dx of the patient.
Signs & Symptoms: Asterisk (*)
those that are present in this patient.
List diagnostic tests used to manage
this pathology: Asterisk (*) those that
are actual in the patient.
Include APA Reference List and in-text citations.
Adalinda Elizondo 09-20-2020
Virtual Clinical S.J. 88 yrs/ African American/ Female
Sachwani
The patient has type 2 diabetes
mellitus and due to the illness she
has developed poor circulation
rendering the wound to receive the
nutrients it needs to heal thus
delaying the healing process.
Hyperglycemia leads to osmotic
diuresis and subsequent decreased
oxygenation and perfusion. High
blood glucose causes stiffening of
the arteries, narrowing of blood
vessels, and diabetic neuropathy,
which is nerve damage throughout
the body, particularly the limbs.
Increase pain on the
wound.
Redness around the
wound.
Warmth around the wound.
Necrosis is present.
Underlying structures
becoming visible (tendon,
bones, muscle)
Minimal granulation.
Inflammation.
Large amount of exudate
(serous, sanguineous,
purulent)
Poor wound edges.
Erythema on the periwound skin.
Excoriated peri-wound
skin.
Gabapentin 300 mg PO TID
*Insulin glargine, 26 units Subq
*Insulin aspart, 1 unit for 10g
carbs
Simvastatin 40mg PO qPM
Poor wound healing of right below the knee amputation (BKA).
The cause of this pathology
which is improper wound
healing is due to the patient’s
underlying medical
complications. Poor wound
healing is when the body is not
able to supply the wound with
sufficient nutrients to help aid
in healing.
*CBC
*Wound Culture and
Sensitivity
*Serum Glucose
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Patho Map
2
Initial Assessment Data r/t Priority Nsg Dx:
Highest Priority Nursing Dx:
Plan: S/T Goal:
Interventions:
Rationale for Nsg Dx #1 (number items to correspond
with interventions; cite/quote references and page
numbers):
Evaluation::
Skills Used for this Nsg Dx:
Explore potential Legal/Ethical Issues r/t caring for patient:
Risk for infection related to compromised host
defenses secondary to diabetes mellitus.
Risk for falls related to loss of limb.
Risk for infection related to compromised
host defenses secondary to diabetes mellitus.
The person will report risk factors associated
with infection and precautions needed, as
evidenced by describing the influence of
nutrition on prevention of infection.
Assess nutritional status to provide adequate
protein and caloric intake for healing.
Maintain aseptic technique for all invasive
devices, changing sites, dressings, tubing,
and solutions per policy guidelines.
Assess the individual’s personal hygiene
habits; correct any be havior that increases
risk for infection.
Explain that the usual signs of infection may
not be present (e.g., fever, chills).
All people are at risk for infection. Secretion
control, environmental control, and hand
washing before and after individual care
reduce the risk of transmission of organisms
(Carpenito, 2019).
Patients whose host defenses are
compromised, thus increasing susceptibility
to environmental pathogens or his or her own
endangers normal flora (Carpenito, 2019).
Monitor temperature every 4 hours; notify
physician/NP if temperature is greater than
100.8° F.
Patients should notify their physician if a fever is
present because this is sometimes the only sign
of an infection (CDC, 2019).
Promote wound healing for people with
diabetes, control blood sugar levels to help
prevent wounds from developing and to
support healing and recovery (Grieger, 2019).
Goal was successfully met as the patient was
able to perform a return demonstration on
proper sterile dressing change on wound and
verbalized adequate food groups for nutrition
intake.
Beneficence related to doing what is in the
best interest of the patient and taking positive
actions to help keep the patient’s wound free
from infection.
Impaired physical mobility related to loss of
limb.
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Patho Map
3
Use back of page as necessary for all sections.
Initial Assessment Data for 2nd Highest Nsg Dx:
Nsg Dx #2:
Plan: S/T Goal:
Interventions: Cite reference with item.
Rationale for Nsg Dx #2 (number items to correspond
with interventions; cite/quote references and page
numbers):
Evaluation:
Skills Used for this Nsg Dx:
Safety Concerns when caring for this patient:
APA Reference List on back of page:
The patient has a below the knee amputation
and will need to teachings on methods to
properly move independently within the
environments such as bed mobility, transfers,
ambulations.
Impaired physical mobility related to loss of
limb.
The individual will report increased strength
and endurance of limbs, as evidenced by the
use of safety measures to minimize potential
for injury.
Teach the patient to perform active ROM
exercises on unaffected limbs at least four
times a day.
Explain the purpose of progressive mobility,
passive and active ROM exercises.
Refer to ROM exercises with photos for
specific instructions and photos of passive
ROM .
Provide written instructions for prescribed
exercises after demonstrating and observing
return demonstration.
Medicate for pain as needed, especially
before activity.
Ensured patient’s safety by proper positioning
the patient and hospital bed when using the
Hoyer lift when moving patient in and out of
bed.
Patient was able to perform active ROM
successfully and performed return
demonstration on passive ROM
independently on the upper extremities and
the left limb.
Performing ROM exercises is essential for the
patient to prevent deep vein thrombosis and
muscle atrophy (Carpenito, 2019).
Prolong sitting can put the patient at risk for
left leg amputation due to poor circulation
from sedentary lifestyle and peripheral
neuropathy (Terranova, 2015).
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Patho Map
4
Date Progress Notes
References:
Terranova, A. (2015). The effects of diabetes mellitus on wound healing. Plastic surgical nursing : official
journal of the American Society of Plastic and Reconstructive Surgical Nurses, 11(1), 20–25.
Grieger, L. (2019). Five nutrition tips to promote wound healing. Eat right: academic of nutrition
and diabetes. Retrieved on September 21, 2020, from www.eatright.org.
Carpenito, L. (2019). Handbook of nursing diagnosis. (15th ed.) (p.g. 305, 329, 336). Walters
kluwer publishing.
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