Medical-Surgical Nursing:Assessment and Managementof Clinical Problems 9th Edition by Sharon Lewis,Shannon Ruff Dirksen,Margaret McLean Heitkemper,Linda Bucher

Exercise 16

CASE STUDY: Inflammation Patient Profile G.K., a 28-year-old patient who has type 1 diabetes, is admitted to the hospital with cellulitis of her left lower leg. She had been applying heating pads to the leg for the last 48 hours but the leg has become more painful and she has developed chills. Subjective Data
• States that she has severe pain and heaviness in her leg
• States she cannot bear weight on her leg and has been in bed for 3 days
• Lives alone and has not had anyone to help her with meals Objective Data Physical Examination
• Irregular shape, yellow-red, 2-cm diameter, 1-cm deep, open wound above the left medial malleolus with moderate amount of thick, yellow drainage
• Left leg red and swollen from ankle to knee
• Calf measurement on left 3 inches larger than on right
• Temp: 102°F (38.9°C)
• Height: 5 ft, 4 in (160 cm)
• Weight: 184 lb (83.7 kg) Laboratory Tests
• White blood cell (WBC) count: 18,300/µL (18.3 × 103/L; 80% neutrophils, 12% bands)
• Wound culture: Staphylococcus aureus
-Priority Decision: Based on the assessment data provided, what are the priority nursing diagnoses? Are there any collaborative problems?