Med Surg Careplan-Cellulitis
Topics: Nursing, Varicose veins, Heart, Surgery, Nursing care plan, Trigraph / Pages: 5 (498 words) / Published: Aug 4th, 2014

Date of care:_______3/27/14 _______________ Client Initials:___GW___ Sex:___M__ Age:__56__ Rm#__308-1___
Religion:______ Allergies:_______N/K/A __________ Admission date:____3/24/14______ Code status___FULL___
Admitting diagnosis ___Cellulitis and Infected Left Leg Ulcer_____ ________________________________
Social Hx:_____________________________________________________ ___________________________________
PMH:___MRSA NARES, DVT RIGHT FEMORAL, SAD, DEPRESSION, STATUS POST LEFT HIP REPLACEMENT, ULCERS- STASIS, VERICOSE VEIN STRIPPING, ALCOHOL ABUSE, DRUG ABUSE Recent Surgeries ____LEFT HIP REPLACEMENT, VERICOSE VEIN STRIPPING________________________
Chief Complaint _____LEFT LEG PAIN__________________________________________________________
Narrative Note/SBAR:
____GW is a 56 year old male, admitted from a nursing home 3/25/14. He was complaining of left leg pain of his infected leg and was diagnosed with Cellutitis and infected ulcer wound of the left leg. He is a full code, NKA, and AO x 3. He is on CONTACT precaution. He has a history of MRSA Nares from February, with a present culture still pending. Other past history includes Schizo-affective Disorder, depression, DVT right femoral, hip replacement, stasis ulcer drug abuse, and alcohol abuse. He is NPO, scheduled to go into surgery for wound debridement of the leg left/ankle. He has a 22G right outer forearm IV access, being treated with 0.45 NS at 40CC/HR. He is being treated with Piperacillin/Tazob (Zosyn) 3.375G Q6 IVP, and Vancomycin 1.0MG Q12 IVP. Patient has a tendency to act sexually inappropriate, yell, and is uncooperative at times. Stay calm, and firmly ask to change conversation. He is able to tolerate most activity i.e. sitting up in chair, independent feeding, and uses urinal. Due to decreased movement, pt is on pressure reduction air mattress, and SCD post surgery. He refused AM care, and reused Stress test,

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