Medical Diagnosis: Cellulitis A.M. is 45 year old female who came… Medical Diagnosis: Cel

Medical Diagnosis: Cellulitis A.M. is 45 year old female who came… Medical Diagnosis: CellulitisA.M. is 45 year old female who came to the clinic for complaints of a reddened area on her rightleg. Has a history of a mosquito bit on the ankle over the weekend that was itchy. A.M. has ahistory of diabetes mellitus. A.M. is single and hikes with friends on the weekends.Nursing Assessment:A.M.’s lower left leg has an 8 cm diameter, reddened area near the ankle. The area is warm,edematous, tender, and firm to touch. The left lower leg is swollen compared to the right leg.Heart rate (HR) 96 beats per minute and regular rhythm. Blood pressure (Bp) 120/88.Respiratory rate (RR) regular rhythm 18 breaths per minute. Oxygen saturation (O2 sat) 99%.Temperature 101.6 F orally. A.M. states, “Pain is 5/10” pointing to the ankle. Oriented to person,time, and place, but states, “I just don’t feel right.” “it’s really itchy, but feels kind of numb.”Blood glucose 100. Diabetes is controlled with diet and the client states, “I really haven’t hadany problems with it so far.” Skin color is otherwise normal for ethnicity, moist. Mucousmembranes moist and pink. A.M. restless.The nursing assessment above took place on the due date at 1010.Additional Information for the documentation:The nurse elevates the leg and places the client in a comfortable position. The nurse calls thephysician at 1025 requesting an IV, antibiotics, and intravenous fluids (IV) at 100 mL/hr andpain medication. The antibiotic and pain medication with antipyretic are administeredimmediately at 1045. An hour later, the client states the site is “better” 2/10 pain and the clienturinates 150 mL clear yellow urine. Vital signs: HR 90, Bp 122/80, RR 18, Oxygen sat 98%,temp 100.4F  ISBAR Communication Worksheet  Introduction:Nurse’s Name: ___________________  Provider’s name;___________________________ Unit: _______Patient Initials: ______________ Patient Date of Birth: _______________ Room Number _______________  Date: _________________ Time: ________________ Location: _____________________________________  Pre-call preparation: Gather the following information: Patient’s name; age; chart. Rehearse in your mind what you plan to say. Run it by another nurse if unsure. If calling about pain, when and what was last pain medication? If calling about fever, what was the most recent temperature? If calling about an abnormal lab, what was the result of the last test? What is the goal of your call? Remember to start by introducing yourself by name and location. Use area below as a checklist to gather your thoughts and prepare. Situation:  Briefly describe the current situation. Give a clear, succinct overview of pertinent issues :    Background:  Briefly state the pertinent history. What got us to this point?:       Assessment:  Summarize the facts and give your best assessment. What is going on? Use your best judgement:     Recommendation: What actions are you asking for? What do you want to happen next?      Health Science Science Nursing NURSING NSG110 Share QuestionEmailCopy link Comments (0)

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