Question

vital signs T 37, P 80,R 14,BP 120/68.                                 +2 edema great toe and second toe,right foot,warm to touch.                                                                                     + pulses.                                                                                      +2 capillary refill.                                                                        Question: What other assessment should be included for the patient?                                                                          Question: From the readings, what is the most probable cause of the edema?                                            Question: What are two known nursing diagnoses?         Question: What would be included in the nursing care plan?                                                                                           Question: What interventions might be included in the care plan of care for this patient?

Answer 1

# .The other assessment that should be included for this patient is basic blood test including CBC, LFT, RFT ,PT ,PTT ,APTT INR , assess for any bleeding from any site , yellowing of skin and eyes ,colour of the urine , itching of the skin ,fatigue , clay coloured stools , abdominl pain , nausea and vomiting .

#. The most probable cause of the edema is liver disease due to deficiency of albumin .

#. The two known nursing diagnosis are :-

- Edema related to deficient albumin as evidenced by leg swelling

- Anxiety related to disease condition

#. Nursing care plan :

1.Nursing diagnosis -  Edema related to deficient albumin as evidenced by leg swelling

Nursing Interventions :-

- Assess the patient's vital signs, for pitting edema , and skin elasticity

- Monitor intake and output daily

- Assess the breath sounds

- Assessing the blood investigations and taking actions according to the need

- Providing albumin therapy if albumin is less than normal

- Advice patient to elevate the foot

- Administration of prescribed medications

2. Nursing diagnosis -

Nursing Interventions - Anxiety related to the disease condition

- Assess the knowledge level of the patient regarding disease condition

- Encourage the patient to express his or her concerns

- Clear all the doubts and queries in a language which is understood by the patient

- Provide emotional and psychological support to the patient