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Case: Mrs. George is a 74 year old woman who was admitted to the hospital with an ulcer on her right big toe. She has a long history of hypertension and osteoarthritis. She lives alone in a third floor apartment with no elevator. She has been a widow for many years. Her only family, a daughter, lives two miles away. Her closest friend passed away three months ago. Mrs. George states that she has had increasing difficulty walking and hardly ever leaves her apartment any more. She reports cramps in her legs that keep her awake at night. She also states that she ran out of her blood pressure pills and forgot to tell her daughter about it.
Mrs. George is 5'7" tall and weighs 220 lbs. Her current BP is 184/92. The skin on both lower legs is dry and flaky. Both pedal pulses are faint. There is a 1 cm round ulcerated area on her right big toe. MD orders are to change the dressing q8hrs, cleansing the wound with sterile NS. Surgical debridement of the ulcer is planned for later in the week.
List the significant information contained in this scenario.
List any additional data you would like to have about this patient. [What questions would you like to ask? Is there information missing? Is there anything you'd like clarified?]
Identify the specific factors that may be influencing this individual's level of wellness.
Organize the data from this scenario into at least three relevant clusters and identify each piece of data as either subjective or objective.
Identify an appropriate nursing diagnosis for each cluster of data.
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