Client: Cassandra Pynn: 57 year old female

Client: Cassandra Pynn: 57 year old female diagnosed with Cellulitis to Left Great Toe and Foot Past Medical History: Kidney Disease, Diabetes Mellitus Type 2, Gout Goals of Care: R1 Allergies: Strawberries, Morphine Upon admission her left great toe and foot presented as red, hot, tight and shiny, painful with and without palpation, edematous 1+, skin intact, PPP, cap refill adequate. Difficulty ambulating, nurse x1 assistance. Sent for PICC line insertion on admission day. 7 days later Pt continues to have pain and swelling to her left great toe and foot. Vital signs – T- 38.1, Pulse 97 irregular but strong, Resp 22 free and easy, BP 132/84 and 99% RA. 0.9% NS @ 100 cc/hr infusing via PICC line. Labs: CBC, Lytes, BUN, Creatinine and GFR drawn daily. Glucometer 6.5 mmol before breakfast. Medications: Metformin 100 mg PO daily, Colace 100 mg PO daily, Furosemide 20 mg PO daily, Allopurinol 100 PO daily, Ceftriaxone 750mg IV q6h , Acetaminophen 650 mg PO Q4H PRN, Tylenol #2 PO 2 tabs Q6H PRN Appropriate Nursing care plan: Identify the priority nursing diagnosis. A SMART goal for the DX Identify three interventions to address this priority diagnosis o Include an intervention to address 1. Nursing care, 2. Medication Administration, & 3. Education needed o Identify the evaluation criteria that will be used to assess effectiveness of care o Identify the rationale for the priority dx, interventions, evaluation criteria, etc. SCIENCE HEALTH SCIENCE NURSING XHLT 1510

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