Question

Meet the Client: John Mathis
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

Primary nursing diagnosis

*Pain related  to wound infection as manifested by patient having pain score of 8/10 and verbalization of pain.

This is the primary prioriety for this patient because,patient having a pain score of 8/10 which indicates that patient is suffering from a severe pain which force him to stay on bed.So we have to take pain as the primary priority nursing diagnosis.

Nursing actions

Assess the type of wound

Assess the level of apin.(To decide the care)

Provide analgesics as prescribed by the doctor.(To reduce pain)

Reassure the patient (to reduce anxiety)

Provide wound care

Administer antibiotics as prescribed by the doctor.

Provide comfortable position to the patient by using pillows.

Explain treatment process to the patient.

Encourage him to ask doubts and concerns.

Interventions to prevent venous thromboembolism

Regularly assess for any signs and symptoms of venous thromboembolism.

Provide leg excercise to the patient .

provide compressive stockings to increase blood flow in deep veins.

Provide leg elevation above the chest to improve the bllod flow.

Administer anticoagulants as prescribed by the doctor.

Actions to reduce Mr.Mathis's anxiety during the admission process.

*Greet the patient and family with a pleasent smile.

*Nurse should introduce herselfs first.

*Establish a therapuetic rapport with the patient.

*Encourage asking of doubts and concerns.

*Give orientation to the patient about the hospital and his treatment process.
*Allow his family members to stay with him.

*Always seek his opinion while making a decision.

*Give health education about his illness,treatment.followup etc.

*Before every procedures take cocent and explain.