[Solved]: Nursing Care Plan Patient Profile: Logan, a…

Nursing Care Plan Patient Profile: Logan, a 72-year-old was admitted to the medical-surgical unit following a fall at home. They sustained a right lower leg laceration during the incident. In addition to the wound, Logan has a history of urinary incontinence, particularly when engaging in physical activities, and reports some difficulty with balance. Upon admission, Logan’s wound is assessed as a 5 cm x 3 cm irregular-shaped laceration on the anterior aspect of their right lower leg. Medical History: • Type 2 diabetes, managed with oral hypoglycemic medications. • Hypertension, controlled with antihypertensive medications. • Peripheral vascular disease (PVD) Social History: • Lives alone • Independent in activities of daily living • No known allergies • History of smoking, quit 10 years ago. Nursing Assessment: • The wound is moderately deep, extending through the epidermis and into the subcutaneous tissue. • Logan reports moderate pain at the wound site and rates it as 5 out of 10 on the pain scale. • The wound is clean, with no signs of infection. • Peripheral pulses are weak and difficult to palpate in the right lower leg • Capillary refill time is delayed in the affected leg. • Logan has a history of urinary incontinence, exacerbated by physical activities. • Difficulty with balance, uses a cane for ambulation. • Blood glucose levels are elevated on admission. Collaborative Care: • Orthopedic surgery consult for wound exploration and assessment of underlying structures. • Endocrinology consult for diabetes management. • Physical and Occupational Therapy consults for gait and mobility assessment. • Urology consult for evaluation and management of urinary incontinence. Current Assessment at 0700 Night Nurse Report: Logan has been restless throughout the night. They report moderate pain at the wound site and rate it as 5 out of 10 on the pain scale. They were incontinent once overnight and voiced concerns about needing to urinate. Despite reporting they were hungry, they refused anything to eat. Morning Assessment: Upon entering the room, you introduced yourself as their assigned student nurse and verified Logan’s identity. You note they are alert and oriented to person, place, and time. Vital Signs: • Temperature (T): 36.9°C • Pulse (P): 83 bpm • Respiration Rate (R): 16 breaths per minute • Blood Pressure (BP): 122/78 mmHg • Oxygen Saturation (O2 Sat): 98% • Glucometer: 6.1 mmol/L Wound Assessment: Logan’s wound, located on the anterior aspect of their right lower leg, measures 5 cm x 3 cm. The wound is irregularly shaped and moderately deep, extending through the epidermis and into the subcutaneous tissue. A thorough examination reveals: • Clean Wound: No signs of infection are observed during the assessment. • Peripheral Pulses: Peripheral pulses in the right lower leg are weak and slightly difficult to palpate. • Capillary Refill Time: Capillary refill time in the affected leg is delayed, indicating potential circulatory challenges in the lower extremity. Patient Concerns: When asked about their main concerns, Logan states their primary issues at the moment are: • Pain: Expresses discomfort and rates the pain at the wound site as a significant concern. • Urination: Logan states they need to use the bathroom • Hunger: They mention feeling hungry and but expresses no desire for food. Subjective Reports During Your Assessment: • “I’ve been in pain through the night and it’s bothering me now” • “I really need to use the bathroom. Can someone help me with that?” • “I haven’t eaten since yesterday before my fall and I’m feeling hungry”