Patient Data

 

Exhibits

The client has started to wake up more, opening her eyes without stimulation and looking around the room.
Which should the nurse do as the client becomes more aware of her surroundings? Select all that apply.

Rationale for correct choices:

• Infection: The client presents with redness, warmth, swelling, and pain in the left lower leg, accompanied by a small cut and a history of type 2 diabetes. These findings, along with elevated temperature and glucose, indicate a bacterial skin infection requiring prompt treatment with antibiotics to prevent progression.

• Sepsis: Older adults with diabetes and chronic comorbidities are at high risk for systemic infection. The client’s generalized muscle aches, fever, and elevated glucose may indicate early systemic involvement. Interventions to prevent sepsis, such as timely IV antibiotics, monitoring vital signs, and laboratory markers (e.g., WBC, lactate), are crucial to reduce life-threatening complications.

Rationale for incorrect choices:

• Congestive heart failure: While the client has a history of heart failure, the acute presentation of erythema, warmth, and localized swelling suggests infection rather than fluid overload as the priority concern. CHF management is important but secondary in this scenario.

• Kidney disease: Stage 3a chronic kidney disease is a chronic condition and does not explain the acute signs of infection. Monitoring kidney function is important for medication dosing, but it is not the immediate priority.

• Hyperglycemia: The client’s blood glucose is elevated at 252 mg/dL, likely worsened by stress and infection. Hyperglycemia requires monitoring and management, but the underlying infection poses a more immediate threat to health.

• Deep vein thrombosis: DVT can cause leg swelling and pain, but the presence of erythema, warmth, and a break in the skin indicates cellulitis rather than thrombus formation. DVT prevention may be part of ongoing care but is not the priority in this acute presentation.

• Peripheral neuropathy: The client has baseline neuropathy contributing to bilateral leg discomfort, but it does not explain the acute swelling, redness, and warmth. Pain management may be necessary, but infection treatment is urgent.

• Edema: Edema is a symptom present in several chronic conditions, including CHF and PVD, but in this case, localized edema is part of the infection process. Addressing the infection takes priority over general edema management.

A. Excessive aerobic exercise: Moderate aerobic exercise is generally protective for cardiovascular health. The client’s symptoms occurred during normal activity, and there is no indication that his exercise is excessive or harmful, so this is less of a concern.

B. Vegetarian diet: A vegetarian diet is usually associated with lower cardiovascular risk due to reduced saturated fat intake and higher consumption of fiber and antioxidants. This is unlikely to be a contributing risk factor in this client.

C. Family health history: Both parents had heart disease, and the father had diabetes, placing the client at increased genetic risk for cardiovascular disease. Exploring family history further helps identify inherited risk factors and guides preventive strategies.

D. History of hypertension: Although the client’s current blood pressure is controlled with atenolol, hypertension is a known cardiovascular risk factor. Assessing the duration and management of prior hypertension is important to evaluate cumulative risk.

E. Sexual history: While sexual history may be relevant in some cardiovascular assessments (e.g., erectile dysfunction as a marker), it is not a primary risk factor for heart disease in this context and does not require immediate exploration.