What is the priority nursing intervention

Assignment Help Science

Reference no: EM133859993

Assignment:

Boyd is now seen in the pediatrician morning walk-in clinic. He is unable to walk and needs to use a wheelchair. He is accompanied by his mother, who reports that "Boyd is getting worse." He is unable to sleep due to the pain and reports pain at a 9 on a 0-10 scale. He describes the pain as throbbing. His mother states that "I have been giving him the antibiotic, acetaminophen, and ibuprofen, and he continues to have the chills and then he feels very hot." Boyd is having difficulty walking, and he must sit down when he showers. He shares that the areas "drain a lot when I'm in the shower" and that he "mashed one of the spots like the doctor did, and it squirted almost to the shower ceiling...it was really cool."

Boyd's legs look as follows:

Boyd's vitals are 103.5 (oral, °F), 110 BPM, 28 respirations, 86/54 BP, and 97% on room air. Boyd is alert and oriented ×4 and is visibly in pain. He is guarding the leg, and he rates his right knee pain at a 10 when touched. He also grimaces when the right knee is touched. All lesions have extended past the marked borders, and the right leg has nonpitting edema. The lesions on the right upper leg and left lower leg have purulent drainage noted. The right knee is edematous. His heart and lungs are normal without any extra or adventitious sounds. He has hypoactive bowel sounds, and his mother reports that he has not had much of an appetite. His right leg is cool to the touch compared to the left, and the dorsalis pedis pulse on the right is +1 and the left is +2. Capillary refill of the right is greater than 2 s and on the left is less than 2 s. Boyd does report that he has feelings in both legs and feet. He does not report numbness or tingling. He is able to apply equal pressure with bilateral legs and feet. The pediatrician admits Boyd to the pediatric unit of the hospital.

The admission orders are as follows:

Admission Orders
Vital signs every 2 hr while awake
Wound culture and sensitivity NOW
Blood cultures ×2 NOW
Complete blood count with differential
Comprehensive metabolic panel
Clindamycin IV piggyback 350 mg every 4 hr
Ketorolac 2 mg IV every 6 hr as needed, pain
Lactated Ringer's (LR) solution 150 ml/hr
Contact precautions
Up with assist
Strict intake and output
Regular diet
Wound consult

Questions

1. What is the priority nursing intervention? Discuss both outpatient and inpatient nurse responsibility.

2. Which concepts are interrelated with Boyd's alteration in tissue integrity?

3. What concerns you the most?

4. Is there other information you need?

5. How would this alteration in tissue integrity look different in other skin types?

Reference no: EM133859993

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