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

Theost prior nursing diagnosis is

Acute pain related to infected wound as manifested by pain scale reading 8/10.

Pain management is the important and need immediate action to solve. Because of pain may affect the emotional and physical aspect of patient. Pain may cause disturbances in patient. So firstly we need to reduce the pain.

Nursing actions to reduce the pain include provide comfortable position to the patient, administer analgesics and antibiotics, use divertional therapies, etc.

The intervention to prevent venous thromboembolism include being active which means provide exercise to the leg and change the position of leg. Clean the wound and check the patency or blood flow to tissues by checking any signs of cynosis.

To reduce the anxiety of patient firstly we need to develop a rapport with the patient . Introduce the hospital environment to the patient. Explain every procedure before it done and clarify the doubts of patient.