Reference no: EM133844201
Question
You assume care for Mr. Bowden and receive a report from the charge nurse who has started the admissions process. She mentions the labs tests were drawn, and radiology has been notified to transport Mr. Bowden when they are ready to perform the MRI. The nurse tells you she is concerned that the admitting provider might be unaware of the patient's withdrawal symptoms.
You enter Mr. Bowden's room to perform a head-to-toe assessment. You find an obese, unkempt, unshaven man. You verify his identification with double identifiers. Mr. Bowden is alert but repeatedly asks where he is and what time it is. He appears slightly agitated and answers your questions curtly. He complains that the unit is "very loud and irritating" and asks whether you could turn off the lights as they are "really bright."
...Vital Signs...
Temperature: 99.0 degrees Fahrenheit (37.2 degrees Celsius), tympanic...
Heart rate: 100, radial
Blood pressure 140/72 mmHg, right arm, sitting...
Respirations: 20...
Oxygen saturation: 93% via room air per finger probe...
Height: 6 ft 1 in...
Weight: 268 lbs, patient statement...
You hear S1S2 in a regular rhythm with no murmur. Peripheral pulses in the femoral, popliteal, right anterior tibial, right dorsalis pedis, brachial, and radial areas are normal. Left anterior tibial and left dorsalis pedis are nonpalpable. His extremities are generally cool and pale. Capillary refill is normal in upper extremities and right foot but greater than 3 seconds in the left foot. Mucous membranes are pink and moist. Left foot with 4-plus pitting edema and reddened.
No cardiac problems are found. Mr. Bowden's breathing pattern is even and unlabored, and lung fields are clear bilaterally in all fields but slightly diminished in the lower posterior fields. You note the presence of a dry, nonproductive cough that the patient describes as a "smoker's cough" during examination.
Muscle strength and movement is normal in all extremities but you notice some small tremors in both upper and lower extremities during the assessment. Mr. Bowden states "I don't shake"
Neurological examination of cranial nerves II-XII is normal. The patient's gait is steady and his cerebellar function is also normal. Reflexes are hyperreflexive and symmetrical bilaterally in all extremities.
His pupils are equal, 2 mm, with brisk reaction to light.
Mr. Bowden's skin is expected color, slightly cool, and diaphoretic with good elasticity and intact with no lesions except for foot wound.
Mr. Bowden's abdomen is round and his bowel sounds are hyperactive in quality and intensity in all areas. He had a bowel movement this morning that was "normal" brown. He denies any bowel or urinary problems. His urinal at the bedside contains 250 mL cloudy amber urine.
The previous nurse has dressed Mr. Bowden's foot with a moist gauze dressing until the wound consult staff ordered specific dressing changes. She stated "I don't want the tissue to become dry." You note red streaking emanating from the wound, moving towards the calf. The entire right foot appears red and swollen, but the patient states the pain is "the same as usual," ranking it as 6 out of 10 on a numeric pain scale and describing it as constant and throbbing. He grimaces when you touch his foot or ask him to move it, and he has had no relief of pain.
You wash your hands and leave the room.
[LEARNER ACTION: Document your assessment findings.]
Having completed your assessment, you decide to check the chart for laboratory results before reporting your findings to the patient's provider.
[CRITICAL THINKING: What are you concerned about with regard to the patient's current assessment? What types of orders are you going to request and why? Explain this in a Misc. Nursing Note.]