CONCEPT MAP WORKSHEET
DESCRIBE DISEASE PROCESS AFFECTING PATIENT
(INCLUDE PATHOPHYSIOLOGY OF DISEASE PROCESS)
According to Porth’s (2019), chronic venous insufficiency is caused by many things such as, factors that
increase venous pressure, incompetent valves in the veins or an obstruction, decreased function of the skeletal
muscle pumps, inflammatory process and endothelial dysfunction. This causes the blood to flow in other
directions. This can lead to tissue getting congested, edema which is inflammation due to the accumulation of
blood, and eventual impairment of tissue nutrition. This can lead to an ulcer formation which is a shallow sore
caused by the poor circulation. The most common site for these ulcers to form is in the lower legs, around the
ankles.
DIAGNOSTIC TESTS PATIENT INFORMATION ANTICIPATED PHYSICAL FINDINGS
(REASON FOR TEST AND RESULTS)
Josephine Morrow
Electrolytes done to determine cell 80 Y/O Ulcer on the lower leg
function White Female (ankle)
HC03-: 28 (High) DOB: 7/30/1940 Brown pigmentation
Hepatic Function done to see if liver Height: 160 cm Edema
is working properly Weight: 90 kg Inflammation
Albumin: 3.4 (Low) Allergies: Penicillin
Prealbumin: 14.7 (Low)
ANTICIPATED NURSING INTERVENTIONS
Hand hygiene
Obtain vital signs
Assess venous ulcer and skin 2 hours
Inspect dressing and clean ulcer as specified in order
Measure ulcer size and depth
Provide developmentally and culturally appropriate education
Provide multidisciplinary approach to patient education
Instruct patient to keep legs elevated and wear sequential compression
devices
Check providers orders and medication administration record (MAR) in the
electronic health record (EHR)
Provide patient education on fall risk, improving venous return, and wound
care
Make sure patient understands side effects of each medication when able to
administer
Evaluate patient every 1 hour after administration of medication
Make a discharge plan for patient
, vSim ISBAR ACTIVITY STUDENT WORKSHEET
INTRODUCTION Hello, my name is Laura Hasmit I’m the RN calling from the nursing
home care facility
Your name, position (RN), unit you are
working on
SITUATION Josephine Morrow is an 80-year-old white female, the daughter her
daughter had her admitted to this skilled nursing home care facility due
Patient’s name, age, specific reason for visit to concern for her safety with impaired mobility, an unhealthy diet, and
inability to adequately care for herself at home.
BACKGROUND Mrs. Morrow was diagnosed with a venous stasis ulcer on her right
medial malleolus and was brought to the skilled nursing home care
Patient’s primary diagnosis, date of facility 3 days ago (04/12/21) to focus on wound healing, improving
admission, current orders for patient venous return and preventing skin breakdown. Mrs. Morrow has a past
history of COPD, chronic venous insufficiency and deep vein
thrombosis.
ASSESSMENT 0800 04/15/2021 patient received AAOx3. Vital signs: T 98F, HR 95
and regular, Resp. 20 even and unlabored, BP 121/80, O2 sat 94% on
Current pertinent assessment data using head room air, pain 0 in a scale of 0-10. Venous stasis ulcer on the lower
to toe approach, pertinent diagnostics, vital right leg. The ulcer is shallow, 12 cm width, and looks mostly pink to
red, with no signs of necrosis or edema. dressing was clean, dry, and
signs
intact with no signs of drainage or odor. normal saline used to irrigate
wound using sterile precautions and covered with a hydrocolloid
dressing. Sequential compression devices used to prevent
inflammation of the legs. Side rails up x2, bed in lowest position and
call light within reach.
RECOMMENDATION I recommend vital signs be done every 2 hours
Contact the HCP for another order for labs to determine
Any orders or recommendations you may have hepatic function and electrolyte levels
for this patient Perform a wound assessment and dressing change
Reposition the patient to optimize venous return
Provide patient education on improving venous return to
prevent further stasis ulcers, as well as wound care
Continue compression therapy with the use of antiembolism
stocking
Instruct patient to keep legs elevated to improve circulation
DESCRIBE DISEASE PROCESS AFFECTING PATIENT
(INCLUDE PATHOPHYSIOLOGY OF DISEASE PROCESS)
According to Porth’s (2019), chronic venous insufficiency is caused by many things such as, factors that
increase venous pressure, incompetent valves in the veins or an obstruction, decreased function of the skeletal
muscle pumps, inflammatory process and endothelial dysfunction. This causes the blood to flow in other
directions. This can lead to tissue getting congested, edema which is inflammation due to the accumulation of
blood, and eventual impairment of tissue nutrition. This can lead to an ulcer formation which is a shallow sore
caused by the poor circulation. The most common site for these ulcers to form is in the lower legs, around the
ankles.
DIAGNOSTIC TESTS PATIENT INFORMATION ANTICIPATED PHYSICAL FINDINGS
(REASON FOR TEST AND RESULTS)
Josephine Morrow
Electrolytes done to determine cell 80 Y/O Ulcer on the lower leg
function White Female (ankle)
HC03-: 28 (High) DOB: 7/30/1940 Brown pigmentation
Hepatic Function done to see if liver Height: 160 cm Edema
is working properly Weight: 90 kg Inflammation
Albumin: 3.4 (Low) Allergies: Penicillin
Prealbumin: 14.7 (Low)
ANTICIPATED NURSING INTERVENTIONS
Hand hygiene
Obtain vital signs
Assess venous ulcer and skin 2 hours
Inspect dressing and clean ulcer as specified in order
Measure ulcer size and depth
Provide developmentally and culturally appropriate education
Provide multidisciplinary approach to patient education
Instruct patient to keep legs elevated and wear sequential compression
devices
Check providers orders and medication administration record (MAR) in the
electronic health record (EHR)
Provide patient education on fall risk, improving venous return, and wound
care
Make sure patient understands side effects of each medication when able to
administer
Evaluate patient every 1 hour after administration of medication
Make a discharge plan for patient
, vSim ISBAR ACTIVITY STUDENT WORKSHEET
INTRODUCTION Hello, my name is Laura Hasmit I’m the RN calling from the nursing
home care facility
Your name, position (RN), unit you are
working on
SITUATION Josephine Morrow is an 80-year-old white female, the daughter her
daughter had her admitted to this skilled nursing home care facility due
Patient’s name, age, specific reason for visit to concern for her safety with impaired mobility, an unhealthy diet, and
inability to adequately care for herself at home.
BACKGROUND Mrs. Morrow was diagnosed with a venous stasis ulcer on her right
medial malleolus and was brought to the skilled nursing home care
Patient’s primary diagnosis, date of facility 3 days ago (04/12/21) to focus on wound healing, improving
admission, current orders for patient venous return and preventing skin breakdown. Mrs. Morrow has a past
history of COPD, chronic venous insufficiency and deep vein
thrombosis.
ASSESSMENT 0800 04/15/2021 patient received AAOx3. Vital signs: T 98F, HR 95
and regular, Resp. 20 even and unlabored, BP 121/80, O2 sat 94% on
Current pertinent assessment data using head room air, pain 0 in a scale of 0-10. Venous stasis ulcer on the lower
to toe approach, pertinent diagnostics, vital right leg. The ulcer is shallow, 12 cm width, and looks mostly pink to
red, with no signs of necrosis or edema. dressing was clean, dry, and
signs
intact with no signs of drainage or odor. normal saline used to irrigate
wound using sterile precautions and covered with a hydrocolloid
dressing. Sequential compression devices used to prevent
inflammation of the legs. Side rails up x2, bed in lowest position and
call light within reach.
RECOMMENDATION I recommend vital signs be done every 2 hours
Contact the HCP for another order for labs to determine
Any orders or recommendations you may have hepatic function and electrolyte levels
for this patient Perform a wound assessment and dressing change
Reposition the patient to optimize venous return
Provide patient education on improving venous return to
prevent further stasis ulcers, as well as wound care
Continue compression therapy with the use of antiembolism
stocking
Instruct patient to keep legs elevated to improve circulation
