What other assessments should be included for this patient? ?A complete head to toe assessment should be done.? The cause of the edema to the toes should be investigated.? I w

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Option 2:

1. What other assessments should be included for this patient?

 A complete head to toe assessment should be done.  The cause of the edema to the toes should be investigated.  I would assess the skin around his toes for an injury that may not have been noticed by J.P. such as an ingrown toenail, cut, or scrape.  I would do a medical history assessment and determine if he has any conditions that may cause poor circulation, diabetes, and possibly gout. 

2.  From the readings, what is the most probable cause of the edema?

The most probably cause of the edema could be cellulitis since it is warm to the touch.  Cellulitis is an infection of the skin caused by bacteria.  Cellultiis is characterized by redness, swelling, warm skin, and pain in J.P.  

3.  What are two known nursing diagnoses?

Acute pain related to tissue injury

Impaired skin integrity related to tissue swelling 

4.  What would be included in the nursing care plan?

Monitoring J.P. for complication or further skin breakdown of the swollen toes. Also includes monitoring vital signs and lab work for signs of an infection.

Monitoring and keeping J.P. comfortable and free of pain.  This may include elevating the affected foot and assuring pain medication is ordered.  

5.  What interventions might be included in the plan of care for this patient?

Pain management, bed rest until weight bearing status is determined, wound culture if possible, ensure the appropriate lab work is ordered, administering medications ordered such as antibiotics and analgesics.    

Cellulitis. Johns Hopkins Medicine. (2019, November 19). https://www.hopkinsmedicine.org/health/conditions-and-diseases/cellulitisLinks to an external site.

Jarvis, C. (2016). Physical Examination & Health Assessment /: 7th edition. Elsevier.