Question

John Mathis, a 73-year-old male, is treated in the emergency department (ED) for an infected wound on his right foot. John states he was walking barefoot and stepped on something sharp that cut his foot. He treated it with topical antibiotics, but it appears red and inflamed, with purulent drainage. John is admitted to the medical-surgical unit for inpatient wound care treatment.

As part of the admission interview, the nurse asks Mr. Mathis and his wife how they would like to be addressed by the staff. They reply that until they are more comfortable, they prefer to be called “Mr. and Mrs. Mathis.” As the interview continues, Mr. Mathis tells the nurse he has never been hospitalized. He appears anxious and frequently turns to his wife for reassurance.

Mr. Mathis states his pain level is 8/10 and that he has been staying in bed due to his foot pain.

1. What is your patient’s primary (priority) nursing diagnosis? (Must place all three components of a nursing diagnosis for full points.) Why does this take priority?

2. What nursing actions will you take in providing care to your patient? (Please think about the patient holistically. This should be a fairly comprehensive list. Include all necessary interventions related to the primary diagnosis, must be measurable and specific.)

3. What interventions can the nurse implement to prevent venous thromboembolism in Mr. Mathis' legs?

4. What action should the nurse implement to reduce Mr. Mathis' anxiety during the admission process?

Answer 1

Ans) In planning his care, priority nursing diagnosis:

Impaired physical mobility.

Mr. Matthew's limited activities support this nursing diagnosis. Improving mobility is a nursing priority to prevent the many potential complications.
*priority diagnosis will involve the patient- not caregiver.

- Nursing actions will you take in providing care to :

The client will sit in the chair for each meal beginning on the day of admission.

This is a correctly stated goal. The client is always the subject of the goal, and the action is always measurable. This goal includes what Mr. Matthew is to achieve and sets a realistic deadline.
*"RN will assist the patient in.." is a nursing action, not a patient goal.

- Interventions that the nurse implement to prevent venous thromboembolism in Mr. Mathis' legs:

Teach Mr. Matthew to dorsal flex and plantar flex his feet while in the bed and chair. This action stimulates circulation by contracting calf muscles, which increases the venous return of blood to the heart. This decreases pooling of blood in the legs, which helps prevent venous thromboembolism in the legs.

Explain enoxaparin (Lovenox) injections will be administered routinely.
Lovenox is an anticoagulant administered to reduce the rick of venous thromboembolism.

- Action that should the nurse implement to reduce Mr. Mathis' anxiety during the admission process:

Explain the room environment to Mr. and Mrs. Matthew.

This action will reduce the client's anxiety by including the spouse and orienting them both to the room.