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NDx #2: Impaired physical mobility NDx # 3: Risk for falls related to post-

related to restriction of movements as operative condition


evidenced by utilization of crutches for Ndx # 4: Risk for infection related to
standing and walking Objective Cues:
presence of portal of entry for
- Vital Signs: BP: 130/80, Temp: 36.8, PR: microogranism
Subjective cues:
81, RR: 18, Pain Scale: 0/10
- Left foot with bandage Objective Cues:
-“Ang hirap maligo at magbihis mag-
isa, hindi ako makalipat ng pwesto ng - Uses crutches for standing and walking
- Cannot pick up things on the floor - Vital Signs: BP: 130/80, Temp: 36.8,
walang tulong, kailangan ko pa ang PR: 81, RR: 18, Pain Scale: 0/10
asawa ko para tulungan ako.” - incision on left foot
- cannot assume a standing position - (+) incision at left foot
without crutches. - (+) skin graft at left thigh
Objective Cues:

- Vital Signs: BP: 130/80, Temp: 36.8,


PR: 81, RR: 18, Pain Scale: 0/10 MDx: Unhealing wound, left foot; S/P
- Left foot with bandage Debridement left foot under SA 8/21; S/P
- Uses crutches for standing and Debridement split thickness skin grafting
walking 8/27
- Cannot pick up things on the floor Ndx # 5: Self-care deficit related to
Priority Assessment:
impaired mobility secondary to present
- Vital Signs
condition
- Physical Examination
NDx #1: Impaired skin integrity related - History of past illness
Subjective cues:
to post-invasive procedure secondary to - Environment
s/p debridement and skin grafting - Family History
- “Ang hirap maligo at magbihis mag-
- Social History
isa, hindi ako makalipat ng pwesto ng
Objective Cues: - Laboratory results
walang tulong, kailangan ko pa ang
- Assistive Devices
asawa ko para tulungan ako.”
- Vital Signs: BP: 130/80, Temp: 36.8, - Verbalizations
PR: 81, RR: 18, Pain Scale: 0/10
- (+) incision at left foot
- (+) skin graft at left thigh
Ndx #6: Anxiety related to deficit in
knowledge on wound healing and recovery
and, financial constraints and proximity of
the health care institution to residence.

Subjective cues:

-“Di naman makakaapekto sa paglakad ko


itong sugat di ba?”
- “Makakapagtrabaho pa naman ako diba?”
- “Paano na naman sa isang linggo babalik
na naman kami dito para sa check up.
Magkano na naman aabutin ng taxi. Puro
utang na kami.”

Objective cues:
- Vital Signs: BP: 130/80, Temp: 36.8, PR:
81, RR: 18, Pain Scale: 0/10
- (+) facial grimace as the patient tell the
statements

CONCEPT MAP
Patient’s Initials: RA Medical Diagnosis/Chief Complaint: Unhealing wound, left foot; S/P Debridement left foot
under SA 8/21; S/P Debridement split thickness skin grafting 8/27
Age: 41 Gender: M Basis for Prioritization: Maslow's Heirarchy of Needs
Category: 3 Room No.: Male Date Admitted: August 19, 2010 Student Nurse: LUMBRES, Joanna Marie C
Ward 6