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59yo Male with Wound Infection & Type 2 Diabetes Mellitus - Coggle…
59yo Male with Wound Infection & Type 2 Diabetes Mellitus
Psychosocial
client's wife passed away suddenly 6mo prior
client has two adult daughters living out of state
client lives alone
client states his wife's passing was a great loss for him
client has a slight odor - suggestive of poor personal hygiene
client has a history of mood disorders
client states he has had little to no interest in doing things he once found enjoyable now that his wife has passed
client feels sad that he has no role as a husband or father anymore
client is withdrawn and refuses to make eye contact
Medication
Allergic to Cefazolin - causes a rash
controls type 2 diabetes with oral medications
baby aspirin for stroke and MI prophylaxis
Impaired Skin Integrity
client has diagnosed type 2 diabetes
Stage III, 3cm sacral wound
uneven gait causing client to require at least one person's assistance when moving
client exhibits a knowledge deficit for how to properly care for wound - client sprained ankle months ago and prolonged bed rest for the ankle caused the wound on his bottom to start. Client states he has not done anything to care for wound up to this point
client has been diagnosed with hypertension
client is a 17 on the Braden scale placing him at a high risk for further impairment of skin integrity
Nutrition
client is on a diabetic diet
client finds it difficult to adhere to diet
client states he consumes mostly pre-packaged meals as he does not cook
client states he has had a poor appetite over the past few days
client has one meal per day and (if available) one snack at home
Pain
Ondansetron 4mg Q6hrs IV PRN for nausea
Hydromorphone 2mg Q4hrs for severe pain
client complains of continuous pain around sacral wound area
Infection
client was admitted with fever
sacral wound was dirty and had lint in it
client is receiving piperacillin and vancomycin until wound cultures return
wound cultures obtained and sent on wound