Question

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

1. What other assessments should be included for this patient?
2. From the readings, what is the most probable cause of the edema?
3. What are two (2) nursing diagnoses related to the patient's situation?
4. What would be included in the nursing care plan? Explain your answer.
5. Discuss three (3) interventions that might be included in the plan of care for this patient. Explain your answer.

Answer 1

Other assessments should be included for this patient

• Assessment of skin to rule out any active wound.
• Fasting blood glucose value and Random blood glucose value to identify risk of diabetes
• Past medical history of diabetes
• History of smoking habit to identify peripheral vascular occulusive disease.
• Type of edema. Pitting or non pitting
• History of paronychia of nail.
• Assessment of nail bed.
• Assessment of the skin turgor.
• Aseessment of surrounding skin.
• Skin assessment, colour of the toes, any discahrge etc
• Types of shoes wearing
• Blood studies, WBC, Total count, CRP to rule out any avtive infection etc

Most probable cause of the edema

From the assessment data, the most probable cause of edema may be due to prolonged capillary refill time.The usual capillary refill time is less tan 2 seconds. Within less than 2 seconds the usual pink color returns indicating adeqaute peripheral circulation. Capillary refill time more than 2 second indictaing any peripheral vasoconstriction and decreased peripheral circulation . This can results in edema formation.

2 Nursing diagnosis

Acute pain over the great toe and second toe of right foot related to inflammatory process as evidenced by patient reports pain as 6/10 in a pain rating scale.

• Reassess the pain scale score
• Assess the type of pain
• Identify the triggreing factors and releiving factors
• Administer cold application over the affected area
• Advise to keep the foot end elevated
• Inform the physician if interventions dosent work
• Administer the analgesics as per physicians order.

Impaired skin itegrity related to impaired circulation as evidenced by presence of +2 degree edema over the great toe and second toe of right foot.

• Assess the skin, consistency, colour, any discharge etc
• Advise to keep the foot end elevated.
• Carefully monitor the foot for any wound
• Apply skin soothening oinments

Three interventions that might be included in the plan of care for this patient.

1.Keeping the foot end elevated: Since the patient is having +2 degree of edema of great toe and second toe of right foot, foot end elevation may promote venous return and thus helps in reducing the edema. Advise the patient to not to stand for a prolonged period of time and not to sit for a prolonged period of time, this may further increase the risk of edema. The patient can lie down with leg supported by extra pillows.

2.Careful monitoring of the feet and daily foot care: Advise the patient to carefully monitor his feet with the help of a mirror.Some times the wounds located behind the fingers and in between the fingers may go unnoticed. This can develop in to a sore and can develop serious infections. In case of diabetic wound and peripheral vascular diseases, usually the patient never feel any pain. This can further increases the size of the wound and can develop serious complications like unhealed sore, diabetic wound etc. Hence foot care and daily examination of foot is very much important.

3. Monitoring the blood glucose value: Its important to regularly monitor the patients blod sugar value to identify the risk of Diabetes Mellitus. In DM also, pheripheral wounds and diabetic foot wounds are developed.hence closely monitor the FBS, RBS, PPBS etc at regular interval.

4. Monitor the peripheral vascular blood flow: It helps to rule out any occlusive disorders of foot.