Name: A. H. Age: 59, Sex: Male, Race: Caucasian Marital Status: Widower
Reason for admission: Infected ankle wound from bed rest.
Medical History: Depression, DM Type 2, Infected sacral wound.
(A). Psychosocial Assessment Data:
* Patient oriented to time, place and person (X3).
* Patient is emotionally unstable and exacerbated by the death of wife 6 month ago.
* Patient is bed bound, and has not been eating well.
* Risk for loneliness related to loss of spouse as evidence by patient exacerbation and not eating well
* Assist patient with ADL’s including (bathing, dressing and oral hygiene).
* Encourage patient to verbalize his feeling and try to engage him in discussion if he wants to and time permit.
* Provide patient with nutritional meal, and identify patient favorite diet with patient,
* Ensure that patient's chosen diet is rich in protein and other nutrients that will aid wound healing.
(B). Physiologic Integrity Assessment Data:
* Patient has Diabetic type 2.
* Infected wound which developed while on bed rest following an ankle sprain.
* Patient need support to ambulate.
* Patient has unstable gait and his on fall precaution.
* Impaired mobility related to unstable gait evidence by patient history of fall and ambulatory support.
* Risk for Impaired skin integrity related to decrease mobility.
* Make sure infected wound site is clean using aseptic wound care procedure.
* Ensure that open wounds are well covered after cleaning.
* Ensure patient personal hygiene and oral care is done daily.
* Change patient linen and underwear when moist to prevent skin breakdown.
* Ensure that patient is constantly repositioned to prevent skin breakage.
(C) Self Care Assessment Data:
* Patient has a risk for fall related to prior fall