Exhibits

Click to highlight the findings that the nurse should report to the provider. To deselect a finding, click on the finding again.

Nurses' Notes

2 weeks ago, 0940:

Client presents to clinic with reports of feeling unwell for the past few weeks. Client states, "I have a sore that won't get better on my right foot." Client removed gauze bandage to reveal open wound 3 cm x 4 cm on right foot; draining small amount of purulent drainage. Client awake and alert; chest clear to auscultation; heart tones audible with no abnormal heart tones heard. Client reports frequent urination, increased thirst, and recent 4.5 kg (10 lb) weight loss without trying. Client denies pain but reports experiencing nausea. BMI is 27.

Vital Signs

2 weeks ago, 0945

Temperature 38.3° C (100.9°F)

Heart rate 104/min

Respiratory rate 19/min

Blood pressure 98/74 mm Hg

Oxygen saturation 97% on room air

Laboratory Result

2 weeks ago, 1020:

WBC Count 9,500/mm3 (5,000 to 10,000/mm3)

Blood glucose 250mg/dL (74 to 106 mg/dL)

Triiodothyronine (T3) 200mg/dL (70 t0 205mg/dL)

Rationale for Correct Findings:

• Open wound with purulent drainage: A non-healing wound with purulent drainage indicates a possible localized infection. In clients with hyperglycemia or diabetes, wounds are at higher risk for complications, including delayed healing and progression to systemic infection.
• Client reports frequent urination, increased thirst, and recent 4.5 kg (10 lb) weight loss without trying. These are classic symptoms of hyperglycemia and potential new-onset diabetes mellitus which should be further evaluated.
•  Client reports experiencing nausea which could be related to hyperglycemia, infection, or other systemic issues.
• Blood glucose 250 mg/dL: This value is significantly elevated and suggests poorly controlled blood glucose levels. Hyperglycemia impairs wound healing, increases infection risk, and can be a sign of undiagnosed or uncontrolled diabetes.
• Temperature 38.3° C (100.9°F): A fever indicates a systemic inflammatory or infectious process. In combination with a draining wound and hyperglycemia, this raises concern for a potential infection requiring medical intervention.
• Blood pressure 98/74 mm Hg: While not critically low, this borderline hypotensive value may reflect early signs of systemic infection or dehydration. It is especially concerning in the context of fever, tachycardia, and possible sepsis.
• Heart rate 104/min: Tachycardia can be a compensatory response to fever, infection, or hypotension. When paired with fever and possible infection, it may indicate early sepsis or systemic involvement and warrants immediate reporting.

Rationale for Incorrect Findings:

• WBC Count 9,500/mm³: This value falls within the normal range and does not alone suggest infection. However, WBC counts may remain normal in some clients with infections, especially those who are immunocompromised or have chronic conditions.
• Respiratory rate 19/min: This is within the normal range and does not independently indicate respiratory distress or systemic compromise at this time.
• Oxygen saturation 97% on room air: Oxygen saturation is adequate and suggests no immediate respiratory compromise. It does not require urgent attention in this scenario.
• Triiodothyronine (T3) 200 mg/dL: This is within the normal range and unrelated to the client’s current presenting issues. Thyroid dysfunction is not suggested by the symptoms or labs at this time.