NIGHTINGALE COLLEGE
DIRECT-FOCUSED CARE: CONCEPT MAPPING ASSIGNMENT WORKSHEET
NURSING PROCESS TEMPLATE: Concept- Inflammation
Assessment (Recognizing Cues) James Walker who is a 72-year-old male presented to the
ED with complaints of increasing swelling and redness to
Which client information is relevant? What client data is most
his left lower leg. Patient reports a recent scratch to left
important? Which client information is of immediate concern?
shin while gardening 3 days ago.
Consider signs and symptoms, lab work, client statements, H &
P, and others. Consider subjective and objective data. Medical Hx: Type 2 Diabetes Mellitus, Hypertension
(HTN)
Subjective Data:
“My leg is really sore and feels hot.”
“I’ve been feeling tired and a little feverish.”
“It’s getting harder to walk because of the pain.”
Objective Data:
VS: Temp 101.6F, 104HR, RR20, 132/78, pain
5/10, O2 Sat 97%RA
Left shin: red, warm to touch, swollen, tender.
Skin appears shiny and stretched. Scratch noted
to left anterior shin
Labs: White Blood Cell (WBC) 14,800, Blood
glucose 198mg/dL, CRP 12, ESR 23
Immediate Concern:
Evidence of systemic inflammation (elevated
temperature, tachycardia, elevated WBC)
Potential for infection progression possibly going
from cellulitis and developing into sepsis
Compromised circulation and tissue perfusion in
a diabetic patient
Risk of delayed wound healing or necrosis due to
diabetic vascular changes
Client conditions that are consistent with the cues:
Analysis (Analyzing Cues)
The cues all strongly suggest the patient is experiencing
Which client conditions are consistent with the cues? Do the cues
acute cellulitis
support a particular client condition? What cues are a cause for
concern? What other information would help to establish the
significance of a cue? Client conditions that are consistent with the cues:
History of Type 2 Diabetes increases risk of poor
wound healing and infection
Elevated temp of 101.6F
Elevated HR (tachycardia) of 104bpm
Elevated WBC lab with value of 14,800, elevated
ESR 23, and elevated CRP 12
Localized signs of infection which include
erythema, swelling, and warmth
Elevated blood glucose may further impair
immune response and wound healing
What cues are a cause for concern:
Fever and tachycardia suggest systemic
involvement.
Page 1 of 12
, Progressing redness, warmth, and swelling raise
concern for spreading infection
Elevated WBC is a lab indicator of infection.
Elevated ESR and CRP are inflammatory markers
and value suggests inflammatory response
History of diabetes compromises immunity and
wound healing, while increasing risk of
complications like abscess, ulceration, or sepsis.
Elevated blood glucose (220 mg/dL) may be
stress-related but could also signal poor glycemic
control, contributing to poor immune response.
What other information would help to establish the
significance of a cue?
Wound culture and sensitivity results to identify
the organism and guide appropriate antibiotic
therapy.
Pain scale rating to evaluate the extent of the
pain and trend over time
Assessment of perfusion including capillary refill
and pulses to rule out ischemia or necrotizing
infection.
Patient medication lists to identify
immunosuppressants or previous antibiotic use.
What explanations are most likely?
Analysis (Prioritizing Hypotheses)
The most likely explanation for Mr. Walker’s clinical
What explanations are most likely? What is the most serious
presentation is acute cellulitis at the site of his recent
explanation? What is the priority order for safe and effective care?
In order of priority, identify the top 4 client conditions.
scratch to left shin. This is supported by signs and
symptoms of erythema, swelling, warm to touch,
tenderness and systemic symptoms which include fever,
elevated labs of WBC, ESR, and CRP. His diagnosis of
diabetes also increases his risk for infection and
complicated healing process.
What is the most serious explanation?
The most serious concern is that the localized infection
may be progressing towards sepsis, which is a potentially
life-threatening response to infection that requires
immediate medical attention. Symptoms like fever,
tachycardia, and leukocytosis are suggestive of systemic
involvement
What is the priority order for safe and effective care?
1. Sepsis or potential for the progression to develop
into sepsis
2. Acute Cellulitis
3. Hyperglycemia
4. Impaired skin integrity
What are desirable outcomes?
Planning (Generate Solutions)
1. Infection will be controlled, with reduced signs of
Page 2 of 12
DIRECT-FOCUSED CARE: CONCEPT MAPPING ASSIGNMENT WORKSHEET
NURSING PROCESS TEMPLATE: Concept- Inflammation
Assessment (Recognizing Cues) James Walker who is a 72-year-old male presented to the
ED with complaints of increasing swelling and redness to
Which client information is relevant? What client data is most
his left lower leg. Patient reports a recent scratch to left
important? Which client information is of immediate concern?
shin while gardening 3 days ago.
Consider signs and symptoms, lab work, client statements, H &
P, and others. Consider subjective and objective data. Medical Hx: Type 2 Diabetes Mellitus, Hypertension
(HTN)
Subjective Data:
“My leg is really sore and feels hot.”
“I’ve been feeling tired and a little feverish.”
“It’s getting harder to walk because of the pain.”
Objective Data:
VS: Temp 101.6F, 104HR, RR20, 132/78, pain
5/10, O2 Sat 97%RA
Left shin: red, warm to touch, swollen, tender.
Skin appears shiny and stretched. Scratch noted
to left anterior shin
Labs: White Blood Cell (WBC) 14,800, Blood
glucose 198mg/dL, CRP 12, ESR 23
Immediate Concern:
Evidence of systemic inflammation (elevated
temperature, tachycardia, elevated WBC)
Potential for infection progression possibly going
from cellulitis and developing into sepsis
Compromised circulation and tissue perfusion in
a diabetic patient
Risk of delayed wound healing or necrosis due to
diabetic vascular changes
Client conditions that are consistent with the cues:
Analysis (Analyzing Cues)
The cues all strongly suggest the patient is experiencing
Which client conditions are consistent with the cues? Do the cues
acute cellulitis
support a particular client condition? What cues are a cause for
concern? What other information would help to establish the
significance of a cue? Client conditions that are consistent with the cues:
History of Type 2 Diabetes increases risk of poor
wound healing and infection
Elevated temp of 101.6F
Elevated HR (tachycardia) of 104bpm
Elevated WBC lab with value of 14,800, elevated
ESR 23, and elevated CRP 12
Localized signs of infection which include
erythema, swelling, and warmth
Elevated blood glucose may further impair
immune response and wound healing
What cues are a cause for concern:
Fever and tachycardia suggest systemic
involvement.
Page 1 of 12
, Progressing redness, warmth, and swelling raise
concern for spreading infection
Elevated WBC is a lab indicator of infection.
Elevated ESR and CRP are inflammatory markers
and value suggests inflammatory response
History of diabetes compromises immunity and
wound healing, while increasing risk of
complications like abscess, ulceration, or sepsis.
Elevated blood glucose (220 mg/dL) may be
stress-related but could also signal poor glycemic
control, contributing to poor immune response.
What other information would help to establish the
significance of a cue?
Wound culture and sensitivity results to identify
the organism and guide appropriate antibiotic
therapy.
Pain scale rating to evaluate the extent of the
pain and trend over time
Assessment of perfusion including capillary refill
and pulses to rule out ischemia or necrotizing
infection.
Patient medication lists to identify
immunosuppressants or previous antibiotic use.
What explanations are most likely?
Analysis (Prioritizing Hypotheses)
The most likely explanation for Mr. Walker’s clinical
What explanations are most likely? What is the most serious
presentation is acute cellulitis at the site of his recent
explanation? What is the priority order for safe and effective care?
In order of priority, identify the top 4 client conditions.
scratch to left shin. This is supported by signs and
symptoms of erythema, swelling, warm to touch,
tenderness and systemic symptoms which include fever,
elevated labs of WBC, ESR, and CRP. His diagnosis of
diabetes also increases his risk for infection and
complicated healing process.
What is the most serious explanation?
The most serious concern is that the localized infection
may be progressing towards sepsis, which is a potentially
life-threatening response to infection that requires
immediate medical attention. Symptoms like fever,
tachycardia, and leukocytosis are suggestive of systemic
involvement
What is the priority order for safe and effective care?
1. Sepsis or potential for the progression to develop
into sepsis
2. Acute Cellulitis
3. Hyperglycemia
4. Impaired skin integrity
What are desirable outcomes?
Planning (Generate Solutions)
1. Infection will be controlled, with reduced signs of
Page 2 of 12
