SOLVED623

A nurse is caring for a client. Medical History Nurses’ Notes Diagnostic Results Vital Signs Nurses’ Notes Day 1: 1100: Caring for client who has type I diabetes mellitus who has foot ulcer. Client is alert and oriented to person, place, and time. Ulceration of right great toe, partial thickness, pale wound bed with slough, margins well-defined, is non-edematous and cool. Client reports pain level of 8 when walking and 5 when sitting on a 0 to 10 pain scale. Day 3: 0930: Skin to bilateral lower extremities have decreased pigmentation, shiny, with hair loss to mid-calf; +2 bilateral peripheral pulses; +1 posterior tibial to affected leg. Capillary refill delayed to lower extremity nail beds. Client reports pain is 6 when walking and 2 when sitting on a 0 to 10 pain scale. Pain treated with opioids by mouth as needed for pain. For each assessment finding, click to specify if the assessment finding is consistent with an arterial ulcer, a venous ulcer, or a diabetic ulcer. Each finding may support more than one disease process. Assessment Findings Arterial Ulcer Venous Ulcer Diabetic Ulcer Hair loss Pale wound bed History of hypertension Skin cool to touch +1 posterior tibial pulse
SCIENCE
HEALTH SCIENCE
NURSING

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