L. G. is a 68-year-old man who goes to the hospital emergencydepartment with a complaint of left foot pain. He has a seven-yearhistory of type 2 diabetes that is controlled with metformin(Glucophage) 500 mg orally twice daily. States he stepped on“something” in the yard a few days ago and is unable to bear weighton the left foot. Has been nauseated and “just haven’t feltgood”
Upon Physical Examination, Vital signs include: Blood pressure160/90, pulse 110, respirations 24, temperature 101.8° F. His leftfoot is swollen, red, and warm to touch with an open area on theball of the left foot near the first metatarsal, with tissue lossand irregular wound margins. The open area measures 2 cm indiameter, with a moderate amount of thick yellow drainage. Thenurse notes bilateral paresthesia in lower legs.
1. Are the client’s manifestations of inflammation local orsystemic?
2. What signs and symptoms does this patient present withindicating infection and inflammation?
3. What blood work would you expect ordered for thispatient?
4. What are a priority POTENTIAL AND ACTUAL nursing diagnosisfor this patient? What evidence supports this selection?
