In: Nursing
J.P is a 45-year-old man who presents to the
outpatient clinic with two swollen toes on his right foot. He does
not recall injuring his foot.
Subjective Data
Pain level is a 6/10 location = right foot,
throbbing
Works as a truck driver
Objective Data
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
Questions
What other assessments should be included for this patient?
From the readings, what is the most probable cause of the edema?
What are two (2) nursing diagnoses related to the patient's situation?
What would be included in the nursing care plan? Explain your answer.
Discuss three (3) interventions that might be included
in the plan of care for this patient. Explain your
answer.
In drivers are especially at risk to develop varicose. Long distance drivers often sit for hours, some times more than 10 hours. So risk to develop varicose vein.
Peripheral venous examinations should perform to identify disease. After maintain safety precautions detain physical assessment should be performed. Expose Lower limb and check for changes in skin condition, scar, ulcer, any other venous disease. Symptoms of varicose vein includes swollen blood vessels, bruising, heavy legs, itching and swollen legs.
In case of varicose when the valve inside the legs veins don't keep blood flowing toward heart, instead back up and collects in pools causing blush clusters of varicose vein on skin. Sometimes itmakes leg swollen.
Nursing diagnosis are
1. Impaired skin integrity related to vascular insufficiency
2.Impaired physical mobility related to activity limitations.
3. Disturbed body image related to varicose
Nursing care plan
1.Assessment of varicose. Skin. Pain
2.assess level of activity, movement, disease and sign and symptoms.
3.Assess quality of peripheral pulses
4. Assess temperature change in both legs.
5.check nutritional status
6.Assess history of preveous disease.
Nursing Interventions
Skin integrity
1.Assess Impaired skin integrity. Location of disurbences pain. Scars etc.
2.check for pain
3.check temperature changes
4. Check for peripheral pulses
5.checkrange of motion. Supporting measures to relive pain and disurbences.
5.provide nutrition diet plan
Internation for impaired physical mobility
Assess condition
Give assistance
Support daily care
Maintain circulation.