The nurse is caring for Jose Crixell, an 85-year-old client who has been admitted to the hospital for cellulitis of his lower right leg secondary to a puncture wound he experienced after a fall at home. Jose lives with his daughter and her family since his wife died 2 years ago. The client a history of hypertension and using a cane for stability but is otherwise healthy.

QUESTION

The nurse is caring for Jose Crixell, an 85-year-old client who has been admitted to the hospital for cellulitis of his lower right leg secondary to a puncture wound he experienced after a fall at home. Jose lives with his daughter and her family since his wife died 2 years ago. The client a history of hypertension and using a cane for stability but is otherwise healthy. During shift report, the off going nurse reported Jose’s vital signs to be “within normal limits”; the wound is open and has a scant serosanguinous drainage. The wound is approximately 1 cm round on the lateral side of his lower right leg. The unlicensed assistive personnel (UAP) reports Jose’s current vital signs are as follows: Blood Pressure 165/94, Pulse 101; Respiratory Rate 28, Temperature 101.8°F. The client reports “feeling worse” now compared to previously in the day and generally feeling weak. He reports feeling more pain in his lower right leg, 5/10 on pain scale, and feels his leg is more swollen and red. The client has an antipyretic ordered to treat fever and pain in addition to the IV antibiotics to treat the infection. The last time Jose had the antipyretic acetaminophen was 1200; it is now 1800. The prescription is to administer acetaminophen 650 mg every 4 hr as needed for pain or fever. The antibiotic is due to be administered next at 2200. Jose normally takes an antihypertensive medication once daily but takes no other routine medications; he had the antihypertensive at 0900.

Discuss nursing interventions to address the identifed potential client problems. (Generate Solutions; Planning) a. Instruct students to provide a rationale for their choices.

Discuss the desired client outcomes related to the performed interventions identifed in the concept map as well as for potential client problems. (Generate Solutions; Planning) a. Discuss client responses that demonstrate an improvement of the client problem. b. Identify client responses that indicate worsening of the client condition. (Generate Solutions; Planning)

Discuss safety considerations that should be included when planning care for this client. (Generate Solutions; Planning) (i.e. fall risk)

Identify client education the nurse should provide for this client (i.e. diet, activity, ADLs). (Take Action; Implementation) Discuss client outcomes you would anticipate based on the performed nursing interventions (i.e. improved SPO2 with raising head of bed, increasing amount of oxygen being delivered). Identify how achievement of client outcomes would be evaluated. (Evaluate Outcomes; Evaluation)

Discuss ways to modify or revise the plan of care when client outcomes are not met. (Evaluate Outcomes; Evaluation)

ANSWER

Nursing Interventions to Address Identified Potential Client Problems:

Elevated Blood Pressure: The nurse should assess the client’s blood pressure again to confirm the reading and check for any signs of hypertensive urgency or emergency. If the blood pressure remains elevated, the nurse should notify the healthcare provider for further evaluation and potential adjustment of antihypertensive medication. Additionally, the nurse should encourage the client to engage in relaxation techniques and promote a calm and quiet environment to help reduce anxiety and stress, which can contribute to elevated blood pressure.

 Increased Pain and Swelling: The nurse should assess the client’s pain level using a pain scale and document the characteristics of the pain. Administering the prescribed acetaminophen is appropriate at this time, as it can help reduce both pain and fever (Wells, 2008b). The nurse should also elevate the client’s leg to promote venous return and decrease swelling. Applying cold compresses or ice packs to the affected area can provide further relief. Regularly monitoring the client’s pain level and reassessing the wound for any signs of worsening are important nursing interventions.

Elevated Temperature: The nurse should continue to monitor the client’s temperature regularly and assess for signs of systemic infection. Providing the prescribed antipyretic, acetaminophen, is essential to help reduce the fever and alleviate the discomfort associated with it. The nurse should ensure the client remains well-hydrated to support the body’s immune response and promote adequate thermoregulation. If the temperature remains elevated or the client shows signs of worsening infection, the nurse should inform the healthcare provider for further evaluation and potential adjustment of the antibiotic regimen.

Desired Client Outcomes

 Improvement of Client Problems

– The client’s blood pressure returns to a normal range after appropriate intervention.

– The client’s pain level decreases from 5/10 to a more manageable level.

– The client’s leg swelling and redness decrease or stabilize (De Virgilio, 2015).

– The client’s temperature decreases to within normal limits.

Worsening of Client Condition

– The client’s blood pressure continues to rise, indicating potential hypertensive crisis.

– The client’s pain level increases or does not improve, suggesting inadequate pain management or worsening infection.

– The client’s leg swelling and redness worsen, indicating a progression of cellulitis.

– The client’s temperature remains elevated or continues to rise, suggesting an ongoing or worsening infection.

Safety Considerations

When planning care for this client, safety considerations should include:

Fall Risk: Given that Jose is using a cane for stability, it is important to ensure a safe environment by keeping walkways clear and well-lit. The nurse should assess the client’s mobility and provide assistance as needed. Educating the client and his daughter about fall prevention strategies, such as using handrails and avoiding loose rugs, can help minimize the risk of falls.

Client Education

The nurse should provide the following client education:

Wound Care: Instruct the client and his daughter on proper wound care techniques, including keeping the wound clean and dry, changing dressings regularly, and reporting any signs of increased redness, swelling, or discharge.

Activity Modification: Advise the client to limit weight-bearing activities on the affected leg and encourage rest to promote healing. Discuss the use of assistive devices, such as a walker or crutches, if necessary.

Medication Adherence: Emphasize the importance of taking prescribed medications as directed, including the antihypertensive medication and the antibiotic. Explain potential side effects and the importance of completing the full course of antibiotics.

Anticipated Client Outcomes:

Based on the performed nursing interventions, anticipated client outcomes may include:

 Decreased blood pressure within a normal range.

– Reduced pain and swelling in the lower right leg.

–Stabilization or improvement of wound redness and drainage.

– Decreased temperature within normal limits.

Evaluation of Client Outcomes:

Achievement of client outcomes can be evaluated by:

– Regularly assessing vital signs, including blood pressure, pulse, respiratory rate, and temperature, to determine if they have returned to within normal limits (Nagle, 2022).

– Assessing the client’s pain level using a pain scale and documenting any changes.

– Monitoring the wound for signs of improvement, such as reduced redness, swelling, and drainage.

– Assessing the client’s overall well-being and subjective reports of feeling better, having improved energy levels, and decreased weakness.

Modifying or Revising the Plan of Care:

If client outcomes are not met, the nurse should consider modifying or revising the plan of care by:

Reassessing the client’s condition and conducting a thorough physical assessment to identify any new or worsening issues.

– Consulting with the healthcare provider for further evaluation and potential adjustment of medications or treatment modalities.

– Re-evaluating the wound care plan and considering additional interventions, such as wound cultures or specialist consultation.

– Re-educating the client and family on proper medication adherence, activity modification, and wound care techniques.

References

De Virgilio, C. (2015). Question Sets and Answers. In Question Sets and Answers. https://doi.org/10.1007/978-1-4939-1726-6_59 

Nagle, S. M. (2022, October 19). Wound Assessment. StatPearls – NCBI Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK482198/ 

Wells, N. (2008b, April 1). Improving the Quality of Care Through Pain Assessment and Management. Patient Safety and Quality – NCBI Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK2658/