Report from home health nursing manager

Report from home health nursing manager: Red is an 80-year-old farmer

and war veteran who lives by himself, 20 miles from the nearest city. He has been a widower for 10 years but his son and daughter-in-law, Jon and Judy, live nearby. He was diagnosed with type 2 diabetes about six months ago and recently began taking insulin. We (nurses from the home health agency) have been asked to see him to evaluate a wound caused by wearing shoes that were too tight. The toe was injured about three weeks ago. Red has been treating it by soaking his foot in water. His daughter-in-law, Judy, expressed concerns about his ability to manage diabetes self-care, and he has agreed that she can be present for the conversation. We know he is very independent, alert, and oriented. He drives himself into town at least once a week and spends a lot of time on his computer. Patient Details Patient Data: Male- Age: 80 years. Weight: 109 kg (240 lbs). Height: 183 cm (72 in). Allergies: No known Past Medical History: Diabetes type 2, diagnosed six months ago. Initially treated with oral antidiabetics, but a few weeks ago shifted to insulin. History of Present Illness: The patient developed an ulcer on his big toe three weeks ago. He has been soaking his foot to heal the wound. Recently, he revealed the wound to his family, who called Dr. Baker. Social History: Widower, his son Jon and daughter-in-law Judy live nearby. Primary Medical Diagnosis: Pressure ulcer, right great toe. Type 2 diabetes. Surgeries/Procedures & Dates: L4-5 laminectomy 25 years ago, transurethral resection of the prostate six years ago. Describe 5 statements re this health problem here Describe the purpose of each assessment tool and what the scoring means for care planning. 1. 2. list at least two problems (apply 3 step process: problem, R/T, AEB) you anticipate the patient in the vSim may present:(nursing Diagnosis) 1. 2. Drug Name/Drug Class How the drug works/ is this a safe dose? Indication (For what specific reason is this drug ordered for your resident? Nursing assessments What nursing actions must be done when administering this medication? Side effects/ adverse reactions/ lab monitoring Lab Tests (blood, urine, sputum, cultures, etc): Please complete below for laboratory tests listed TEST Normal Range Purpose Why ordered for this health problem Nursing actions that require assessment or follow up (npo, diet changes, med change) PROCEDURES and DIAGNOSTIC TESTS (oxygen, O2 Sat level, radiography, etc.). Please complete the table for procedures listed in the preparation for vSim. TEST/DATE What is the purpose of this test (text reference) Why ordered for this patient (related to primary dx?) Plan of care implications? Nursing actions that require assess or follow up (npo, diet changes, med change)