Anatomy 2086 Josephine Morrow Vism Packet.
CONCEPT MAP WORKSHEET
DESCRIBE DISEASE PROCESS AFFECTING PATIENT
(INCLUDE PATHOPHYSIOLOGY OF DISEASE
... [Show More] PROCESS)
DIAGNOSTIC TESTS
(REASON FOR TEST AND RESULTS)
PATIENT INFORMATION ANTICIPATED PHYSICAL FINDING
Albumin level test: 3.4
Prealbumin test: 14.7
Test used to detect protein level,
Protein in essential for proper wound healing plays a role in new cell growth
Chronic Venous Insufficiency is improper functioning of the vein valves in the lower extremities.
Pathophysiology including factors such as venous hypertension, incompetent valves in the veins, deep vein
obstructions (DVT) and decreased function of the skeletal muscle pumps.
The clinical manifestation is associated with impaired blood flow. In contrast to the ischemia caused by arterial
insufficiency, venous insufficiency leads to tissue congestion, edema, and eventual impairment of tissue
nutrition.
Mrs. Morrow, 80-year- old
white female who develop a
venous stasis ulcer on her
right medial malleolus while
still living at home. The
current plan of care is
focused on promoting
wound healing, improving
venous return, and
preventing skin breakdown.
Examine the legs for edema,
comparing one leg with the
other
Impaired blood flow
Ischemia caused by arterial
insufficiency
Skin integrity
Perform Hydrocolloid dressing to right lower leg ulcer
Irrigated the wound with normal saline
Teach and educate patient about Antiembolism stocking to left leg and elastic bandage to right leg
Encourage the patient to elevate the leg
vSim ISBAR ACTIVITY STUDENT WORKSHEET
INTRODUCTION My name is Yingyi Huang, student nurse from Nova Southeastern
University. I work on skilled nursing home care facility 0800.
Your name, position (RN), unit you are
working on
SITUATION My patient Josephine Morrow is an obese, 80- year old white female
who developed a venous stasis on her right medial malleolus while still
living at home. She moved into out skilled nursing home care facility 3
days ago.
Patient’s name, age, specific reason for visit
BACKGROUND Mrs. Morrow was admitted on 04/06/2020. Mrs. Morrow has a history
chronic obstructive pulmonary disease (COPD), chronic venous
insufficiency and deep vein thrombosis (DVT). Peripheral arterial
disease is ruled out by duplex ultrasound. Patient are allergic to
Penicillin. Current orders are Acetaminophen 650 mg, Albuterol
inhaler 360 mcg, Aspirin 81 mg, Zinc supplement and Multivitamin.
Patient’s primary diagnosis, date of
admission, current orders for patient
ASSESSMENT Mrs. Morrow is alert and oriented, but sometimes forget of recent
events. Vital signs performed: B/P: 122/82 mm Hg, pulse is 95 per
minute, breathing at 20 bpm, temperature is 97 F, SP02 is 94%. She is
on a regular diet with nutritionals supplement and has been eating the
majority of her meals since admission. Performed pain assessment,
pain, patient states “No, I don’t have any pain.”
She required assistance with positioning in bed and assistance times 1
to get out of bed to the chair or ambulate. Her gait is unsteady and
easily fatigued.
Braden Scale score is 16, and her skin is intact except for the venous
stasis ulcer on the right medial malleolus. She has brown
hyperpigmentation on both lower legs with +2 edema. The venous
stasis is covered with a hydrocolloid dressing, which is due to be
changed. In preparation for her dressing change, she was medicated for
pain half an hour ago. [Show Less]