Michael Johnson Case Summary

1288 Words 6 Pages
Introduction
Clyde Crimeson is a 45-year-old male, admitted to the emergency room after falling in his home. He presents a wound located at his right foot with reddened edges, in addition to a hairline fracture. He is a diabetic with a history of forgetfulness and episodes of falls.
Functional Patterns
The pattern of Nutritional Metabolic is dysfunctional. The following data supports this assessment: The patient has a wound on his right foot. The wound is not drainage but has reddened edges. The following nursing diagnosis were identified as impaired skin integrity: The nurse observed that Clyde had a reddened area on his sacrum, thus having to turn him every 2 hours. This places the patient at a risk for impaired skin integrity. Upon admission,
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Risk for unstable blood glucose in relation to patient’s diabetes as evidence to patient’s glucose reading 175 upon admission and reassessment at 1500 resulting at 190.
2. Acute Pain as evidence by patient verbalizing pain being 3/10 upon admission and 2/10 at 1500 related to patient’s wound and hairline fracture.
3. Bowel incontinence as evidenced by patient accidently soiling the bed at 1300.
4. Impaired skin integrity related to injury as evidenced by patient’s wound on right foot.
5. Impaired memory related to patient’s forgetfulness as evidenced by patient’s inability to remember bits of information.
6. Risk for infection related to patient’s open wound as evidenced by reddened area around the wound.
7. Risk for impaired skin related to prolonged pressure as evidenced by a reddened area around sacrum.
8. Risk for fall related to patient’s history of falls as evidence by Bonnie’s statement of “it’s getting harder and harder to pick him up.”
9. Caregiver role strain, related to wife having to pick him up after falls as evidenced by verbalization by wife. Patient also is experiencing role strain related to wife not wanting to be left alone as evidenced by verbalization by patient.

Nursing Diagnosis

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