Bundley1

Health Assessment

Helene School of Nursing

Kimberly R. Bundley

Coppin State University

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Client Profile: HG is a 54yo WM with Cellulitis, Osteomilitis, Type 2 Diabetes Mellitus and Alcoholism. He was admitted 2/6 with the diagnosis of Osteomilitis of the left foot.

He has had problems with infection and swelling of the left foot off and on since he broke his foot 4 years ago in a motorcycle accident. He states my left foot is getting bigger than

my right and it hurts really bad. At that time he had a fracture of the metatarsals and the malleolus. During admission for treatment is was discovered that he had Type 2 Diabetes

Mellitus. Alcohol abuse developed after the accident. He has never had a bone infection. He has smoked 2 packs if cigarettes per day since age 18. PMH: History of fracture of left

foot 4 years ago, chronic infection of left foot, Type 2 Diabetes Mellitus ,Alcohol abuse and 2 pack per day cigarette for 36 years. Repair of fractured metatarsals and left malleolus

4 years ago. Appearance is disheveled, lacking recent hygiene. Clients have been homeless for several months and only get his meals from the homeless shelter occasionally. He

has held odd jobs in this state for the past 4 years. He had a job as a janitor and lost his job because of the drinking. His wife took his two sons 6 months ago after his motorcycle

accident and he has not seen the since. He states that he is better off with out them. Parents and brothers live in another state. Grandmother age 92 has a history of Diabetes and she

lives in a nursing home. Grand father died of a stroke at the age of 72. Client has a known allergy of rash with a UTI.
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Subjective data Objective Data

“I have so much pain in my left foot and its getting Left foot sensitive to touch, red and swollen small
bigger than my right foot.” amount of serous drainage.

“My foot has been killing me and nothing helps the T 101.4
pain.” B/P 146/88
P 110
RR 24
SpO2 90
Pain 8-9/10

Hgt. 5’11
Wgt. 145lb/66kg
Dexi 380

Labs :
WBC 19,200
RBC 5.0
PLT 350,000

Bone Scan:
Increased radioisotope uptake in the area left malleolus
and 1st, 2nd, and 3rd metatarsals.
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Assessment Findings
Full range of motion without any deficits
Head and Neck Skin warm, dry and flaking intact without rashes or
lesions
Hair Thin without rashes or lesions
Nail Thick and brittle, peripheral intravenous infusion,
without redness and swelling.

Chest Regular even respiratory effort

Bilateral breath sounds

Back and Spine Skin dry warm, spinal curvature straight without
deformities, full range of motion without deficits in
sensation or movement

Upper extremities Strength and sensation intact without apparent deficits

Abdomen Bowel sounds auscutated in all 4 quadrents

No tenderness or palpable mass.
Pelvic
No palpable or tender masses
Lower extremities
Right leg warm, dry, erythematous on anterior surface ,
intact without lesions
Left leg erythmatodeous from the toe to mescal
Lesions 2-3 cm. With small amount of drainage
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Problem List Nursing Diagnosis

1. Infection 1. Risk for infection R/T insufficient knowledge to avoid exposure to pathogens.

2. Pain 2. Altered Comfort R/T inflammation of left foot.

3. Nutrition 3. Altered nutrition less than body requirement r/t being homeless.

4. Exhaustion 4. Fatigue R/T left foot discomfort.

5. Injury 5.Risk for injury R/T decreased muscle coordination

6. Skin sores 6. Risk for impaired skin integrity R/T altered nutritional status and immobility

7. Activity Intolerance 7. Activity intolerance R/T chronic pain secondary to edema AEB 4 year old motor cycle accident

8. Self care 8. Self care deficit R/T psychological impairment AEB being homeless

9. Disruption of usual family process 9. Alter family processes R/T alcohol use AEB client has been drinking Vodka every day since motorcycle accident.
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Primary Diagnosis: Cellulitis with Osteomilitis, Type 2 Diabetes Mellitus, Alcoholism.

Cellulitis: acute infection of the skin and subcutaneous tissue characterized most commonly by local heat redness pain and swelling and occasionally fever malaise chills,

and a headache. Abscess and tissue destruction usually follows if antibiotics are not taken. The infection is more likely to develop in the presence damage skin, poor

circulation or diabetes mellitus. In addition to appropriate antibiotics, treatment includes warm soaks, elevation, and prevention of pressure to the affected area.

Osteomilitis: local or generalized infection of bone and bone marrow. It is usually caused by bacteria introduced by trauma of surgery, by direct extension from a nearby

infection, or via blood stream. Staphylococci are most common causative agents.

Type 2 Diabetes Mellitus: a type 2 diabetes mellitus in which patients are not insulin dependent or ketosis prone, although that may use for correction of symptomatic or

persistent hyperglycemia and they can develop ketosis under special circumstances such as infection of stress.

Alcoholism: extreme dependence on excessive amounts of alcohol, associated with a cumulative pattern of deviant behavior. Alcoholism is a chronic illness with slow

insidious onset which may occur at any age the cause is unknown, but cultural and psychosocial factors are suspect, families of alcoholics have a higher incidence of

alcoholism.
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References

Darlene Como. (Ed.). (2002). Mosby's Medical, Nursing, & Allied Health Dictionary (6th Ed.). St. Louis, Missouri: Moby an Affiliate of Elsevier.

Helen C. Cox. (2002). Clinical Applications of Nursing Diagnosis (4th Ed.) [Adult, child, Women's, Psychiatric, Geronic, and Home Health Considerations]. Philadelphia: F. A.

Davis.

Giddens. (2005). Health Assessment for Nursing Practice (3rd Ed.). .). St. Louis, Missouri: Elsevier-Mosby. (Original work published 1996)

Lynda Juall Carpenito- Moyet. (2006). Nursing Diagnosis Application to Clinical Practice. Philadelphia: Lippincott Williams & Wilkins.

Perry-Potter. (2005). Fundamentals of Nursing (6th Ed.). St. Louis, Missouri: Mosby.