(Solved): Engage Fundamentals Vital Signs Clinical Judgment Case Study with Concept Map s caring for Jose Cr ...

Engage Fundamentals Vital Signs Clinical Judgment Case Study with Concept Map s caring for Jose Crixell, an 85-year-old client who has been admitted to the hospital for his lower right leg secondary to a puncture wound he experienced after a fall at home. The nurse is caring for Jose Crixell, an 85 -year-old client who has been admitted to the hospital for cellulitis of his lower right leg secondary to a puncture wound he experienced after a fall at home. Jose lives with his daughter and her family since his wife died 2 years ago. The client a history of hypertension and using a cane for stability but is otherwise healthy. During shift report, the off going nurse reported Jose's vital signs to be "within normal limits"; the wound is open and has a scant serosanguinous drainage. The wound is approximately $1\mathrm{cm}$ round on the lateral side of his lower right leg. The unlicensed assistive personnel (UAP) reports Jose's current vital signs are as follows: Blood Pressure 165/94, Pulse 101; Respiratory Rate 28, Temperature $101.8^{?}\mathrm{F}$. The client reports "feeling worse" now compared to previously in the day and generally feeling weak. He reports feeling more pain in his lower right leg, $5/10$ on pain scale, and feels his leg is more swollen and red. The client has an antipyretic ordered to treat fever and pain in addition to the IV antibiotics to treat the infection. The last time Jose had the antipyretic acetaminophen was 1200; it is now 1800. The prescription is to administer acetaminophen $650\mathrm{mg}$ every $4\mathrm{hr}$ as needed for pain or fever. The antibiotic is due to be administered next at 2200 . Jose normally takes an antihypertensive medication once daily but takes no other routine medications; he had the antihypertensive at 0900. Assessment Questions 1. Identify the relevant subjective and objective assessment information related to the client's condition and place the findings in the assessment data box below. (Recognizing cues; Assessment) 2. Based upon assessment information identify and prioritize the top 3 client problems. Write one client problem in each of the Client Problem boxes below. (Analyze Cues; Analysis and Prioritize Hypothesis; Planning) 3. Below each client problem, determine and enter the relevant assessment information that supports the identified client problem. (Analyze Cues; Analysis and Prioritize Hypothesis; Planning) 4. Identify important nursing interventions that should be taken to address each client problem and enter them in the related intervention box for the associated client problem. (Take Action; Implementation)