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This Concept Map, created with IHMC CmapTools, has information related to: rataycmap8, Diagnostic Tests related to History of Present Illness, Abnormal Labs related to History of Present Illness, Nursing Diagnoses ???? Diagnosis No. 2, Nursing Diagnoses ???? Diagnosis No. 3, Medications ???? Hospital, Physical Assessment RM, RM Priority Nursing Diagnoses, Skin pink, moist, and intact except for RLE. Evidence of skin grafting on right inner thigh. Healed scar from fasciotomy surgery on right lower leg. Right lower leg is also edematous, red, warm to the touch. Braden score: 16. (sensory perception = 3; moist =3; activity = 2; mobility = 3; nutrition =3; and friction/shear = 2). Skin generally flushed and warm. Integumentary Physical Assessment, Pt is unable to perform ADLs without total assistance. Functional Physical Assessment, Medications ???? Home, RM has a Past Medical History, Pt is currently unable to participate in care. He has no family currently present at the bedside. Pt is not fully oriented to current situation, and cannot be assessed as to whether or not he is coping. Psychosocial Physical Assessment, Last bowel movement was prior to admission. Abdomen firm, tender, & distended. Pt does not show signs of pain with palpation. Bowel sounds present x4 quadrants. Catheter draining dark urine with sediments. Urine output is only at 400cc for the shift. Gastrointestinal Genitourinary Physical Assessment, PERRL but sluggish at 3mm, unable to assess accomodation, remains primarily in sleep state. Pt is A&O to person. Generalized muscle weakness, only noted to move armss. Became less arousable as shift progressed. Unable to assess hand grasps, push/pulls. Patient has a fever of 38.3, given Tylenol PO. No other sensory impairment noted. Pt is arousable enough to take PO medications, ask simple questions. Neuromuscular Musculoskeletal Physical Assessment, Nursing Diagnoses ???? Diagnosis No. 1, Heart rate unstable, primarily tachycardic up to the 120s. Patient is in tachycardic normal sinus rhythm. Peripheral pulses palpable at 1+ & thready. Capillary refill ɛ sec. S1 and S2 heart sounds auscultated. Edema 2+ non-pitting in all extremities. Blood pressure remaining stable from 90s/60s to 110s/70s. Cardiovascular Physical Assessment, History of Present Illness as of 04/2/08 RM, Last VS noted for shift: Temp: 38.3 BP: 96/62 Resp: 22 HR: 112 SpO2: 93% on 40% BiPap Pain: 0/10 Vital Signs Physical Assessment, Lung sounds diminished in lower lobes bilaterally. Some rhonci in upper airways. No cough. Pulse ox stable on 40% BiPap, quickly desats if mask is removed. Clear use of accessory muscles to breathe. Respiratory Physical Assessment, RM ???? Medications