The nurse is caring for Jose Crixell, an 85-year-old client who has been admitted to the hospital for cellulitis of his

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The nurse is caring for Jose Crixell, an 85-year-old client who
has been admitted to the hospital for cellulitis of his lower right
leg secondary to a puncture wound he experienced after a fall at
home. Jose lives with his daughter and her family since his wife
died 2 years ago. The client a history of hypertension and using a
cane for stability but is otherwise healthy. During shift report,
the off going nurse reported Jose’s vital signs to be “within
normal limits”; the wound is open and has a scant serosanguinous
drainage. The wound is approximately 1 cm round on the lateral side
of his lower right leg. The unlicensed assistive personnel (UAP)
reports Jose’s current vital signs are as follows: Blood Pressure
165/94, Pulse 101; Respiratory Rate 28, Temperature 101.8°F. The
client reports “feeling worse” now compared to previously in the
day and generally feeling weak. He reports feeling more pain in his
lower right leg, 5/10 on pain scale, and feels his leg is more
swollen and red. The client has an antipyretic ordered to treat
fever and pain in addition to the IV antibiotics to treat the
infection. The last time Jose had the antipyretic acetaminophen was
1200; it is now 1800. The prescription is to administer
acetaminophen 650 mg every 4 hr as needed for pain or fever. The
antibiotic is due to be administered next at 2200. Jose normally
takes an antihypertensive medication once daily but takes no other
routine medications; he had the antihypertensive at 0900.
3. Discuss nursing interventions to address the identifed
potential client problems. (Generate Solutions; Planning) a.
Instruct students to provide a rationale for their choices.
4. Discuss the desired client outcomes related to the performed
interventions identifed in the concept map as well as for potential
client problems. (Generate Solutions; Planning) a. Discuss client
responses that demonstrate an improvement of the client problem. b.
Identify client responses that indicate worsening of the client
condition. (Generate Solutions; Planning)
5. Discuss safety considerations that should be included when
planning care for this client. (Generate Solutions; Planning) (i.e.
fall risk)
6. Identify client education the nurse should provide for this
client (i.e. diet, activity, ADLs). (Take Action; Implementation)
Discuss client outcomes you would anticipate based on the performed
nursing interventions (i.e. improved SPO2 with raising head of bed,
increasing amount of oxygen being delivered). Identify how
achievement of client outcomes would be evaluated. (Evaluate
Outcomes; Evaluation)
7. Discuss ways to modify or revise the plan of care when client
outcomes are not met. (Evaluate Outcomes; Evaluation)