New Recording 41

Case Study Overview

• Patient Information: Jose, 85 years old, admitted for cellulitis on right lower leg.

• Key Issues: Cellulitis is a bacterial skin infection, often resulting from a wound.

• Background: Puncture wound from a fall at home, lives with his daughter after losing his wife two years prior.

• Medical History: History of hypertension, uses a cane for mobility.

Current Condition

• Vital Signs:

  • Blood Pressure: 165/94 (high)

  • Pulse: 101 (elevated/tachycardia)

  • Respiratory Rate: 28 (tachypnea)

  • Temperature: 101.8°F (fever)

• Symptoms:

  • Patient reports feeling worse, weak, with increased pain in right leg (5/10 on pain scale).

  • Right leg more swollen and red.

• Wound Assessment:

  • Open wound, approximately 1 cm in diameter on the lateral side of the right leg.

  • Scant serosanguineous drainage (pale pink).

Nursing Assessment Findings

Subjective Findings

• Patient expresses feeling worse compared to earlier in the day.

• Reports increased pain (5/10 scale) in the right leg.

• Describes leg as feeling more swollen and red, indicating potential infection.

Objective Findings

• Patient age: 85 years, male.

• Elevated vital signs indicating potential infection and general instability.

• Open wound with specific measurements (1 cm, scant drainage).

• History of using a cane, indicating a risk for falls.

Nursing Diagnosis

• Primary Problem: Bacterial infection (cellulitis).

• Associated Symptoms: Elevated temperature, swelling, redness, and pain.

• Potential Secondary Problems: Impaired comfort due to pain and infection; risk for falls due to age and cane use.

Nursing Interventions

For Infection Management

• Medication Administration:

  • Administer IV antibiotics (dose due at 10 PM).

  • Administer acetaminophen (650 mg every 4 hours as needed for fever/pain).

• Wound Care:

  • Monitor the wound for size and drainage changes.

  • Assess for worsening redness, swelling, or additional drainage.

Pain Management

• Assess and Reassess:

  • Monitor pain level every 4 hours post-medication.

  • Immediate reassessment 30 mins after administering pain medication.

• Positioning:

  • Elevate the right leg to reduce swelling and discomfort.

Fall Prevention

• Assess for Fall Risks:

  • Ensure safety measures are in place (low bed, call light accessible).

  • Educate patient about the importance of using his cane when moving.

• Regular Rounding:

  • Implement hourly rounding to monitor patient status and intervene timely.

Discharge Planning

• Identify Needs:

  • Begin discharge planning upon admission (consider equipment or home health needs).

• Patient Education:

  • Educate on the signs of worsening infection, proper wound care, and medication management.

• Follow-Up Care:

  • Schedule follow-up appointments to reassess health post-discharge.

Transfer and Communication

• Importance of Communication:

  • Clear report during any transitions in care (SBAR method).

  • Ensure all pertinent information is conveyed to receiving staff or facilities.