banjuarearowolo
The nurse is caring for Jose Crixell, an 85-year-old client who has…
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. Assessment Questions 1. Identify the relevant subjective and objective assessment information related to the client’s condition and place the findings in the assessment data box below. (Recognizing cues; Assessment) 2. Based upon assessment information identify and prioritize the top 3 client problems. Write one client problem in each of the Client Problem boxes below. (Analyze Cues; Analysis and Prioritize Hypothesis; Planning) 3. Below each client problem, determine and enter the relevant assessment information that supports the identified client problem. (Analyze Cues; Analysis and Prioritize Hypothesis; Planning) 4. Identify important nursing interventions that should be taken to address each client problem and enter them in the related intervention box for the associated client problem. (Take Action; Implementation)
Educators can choose to instruct students to include relevant information identified during the
discussion questions into the concept map.
1. Discuss special considerations to be made for clients from diverse backgrounds. (Recognize
Cues; Assessment)
a. Elderly client with no family support
b. Clients from diverse backgrounds (i.e. age, culture, socioeconomic status)
2. Identify potential client problems. (Analyze Cues; Analysis)
a. Instruct students to provide a rationale for their choices.
3. Discuss nursing interventions to address the identified potential client problems. (Generate
Solutions; Planning)
a. Instruct students to provide a rationale for their choices.
4. Discuss the desired client outcomes related to the performed interventions identified 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)
5. Discuss safety considerations that should be included when planning care for this client.
(Generate Solutions; Planning) (i.e. fall risk)
6. 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)
7. Discuss ways to modify or revise the plan of care when client outcomes are not met. (Evaluate
Outcomes; Evaluation)
