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Nursing Concept Map : fill the form with the information mentioned


JJ is a 65-year old-female Caucasian. DOB: 6/7/xx, Ht. 66 inches and Wt. 70kg. Religion: Lutheran

History of present illness: Mrs. James went to her local senior center complaining of a “sore that just won’t heal”. The nurse at the senior center referred Mrs. James to Dr. Winters for follow-up. Wound culture obtained at clinic and results are pending. BP: 178/96 mmHg HR: 88-Irregular T: 101.4° F RR: 26 per min. 02 sat 90%. Pain 7/10. Mrs. James has been admitted to the medical/surgical unit for treatment of a diabetic leg ulcer. Primary Medical Diagnosis: Non-healing leg wound.

Past medical diagnosis: Cardiovascular Hypertension, atrial fibrillation, Type 2 Diabetes

Past surgical history: Knee replacement, Diet: 1800 ADA

Medication allergies Penicillin.

Home medications: Glipizide (glucotrol) 10 mg PO twice daily; Capoten (captopril) 50 mg PO twice daily’ Lanoxin (digoxin) 0.125 mg PO daily; Coumadin (warfarin) 5 mg daily PO; Keflex (cefalexin) 500 mg PO every 6 hours PO; Bactrim (sulfamethoxazoletrimethoprim) 800 mg every 12 hours.

Labs: Glucose finger stick 200, WBC 5,100, HgBl 1.5, Hct 36.4%, Plt 158,000,

} a 142, K 4.7, Cl 101, Hgb Alc 7%, pre albumin40, albumin 6.5 Diagnostics: X-ray of the foot, pending results

Widowed patient lives alone with 6 cats. She does not drive but walks,.uses public transportation or rides with friends. Two adult sons live out of state and have limited interaction with the her. ½ PPD smoker since she was “in her 20s”.

Occasional ETOH.

Labs: Glucose finger stick 275, WBC 5,100, HgBl 1.5, Hct 36.4%, Plt 158,000, Na

142, K 4.7, Cl 101, HgbAlc 7%, PT 10.3, PTT 25.7 CK-MB 4.5%, Troponin


Diagnostics: CXR- results pending, EKG results pending.

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