Patient Data

Highlight the finding(s) that require the nurse's attention. Select all that apply.

• Heart rate 88 beats/minute
• Blood pressure 122/72 mm Hg
• Temperature 100.5° F (38° C)
• Reports of pain with ambulation
• Respirations 20 breaths/minute
• Left lower leg with erythema, warm, and swollen
• Blood glucose 252 mg/dL (13.9 mmol/L)
• Capillary refill greater than 3 seconds bilateral lower extremities
• Pain: 2 on a 0 to 10 pain scale, bilateral lower legs described from neuropathy
• Body circumference: Right calf 16.5 in (41.9 cm); left calf 17.25 in (43.8 cm)

Rationale:

• Temperature 100.5° F (38° C): An elevated temperature indicates a potential infectious process. Combined with localized leg symptoms, this suggests systemic involvement and the need for prompt assessment and possible initiation of antibiotics. Fever in older adults may be subtle but still significant. Early recognition helps prevent sepsis or worsening cellulitis.

• Left lower leg with erythema, warm, and swollen: These localized findings are hallmark signs of infection, likely cellulitis, especially given the history of a small cut. Pain and swelling with redness require immediate attention to prevent progression to systemic infection. Early detection allows timely interventions such as IV antibiotics and elevation.

• Blood glucose 252 mg/dL (13.9 mmol/L): Hyperglycemia impairs wound healing and increases the risk of infection. Elevated glucose in a client with diabetes requires prompt management to reduce complications. Poor glycemic control can exacerbate the severity of cellulitis and contribute to poor perfusion. Monitoring and treatment are essential to optimize recovery.

• Capillary refill greater than 3 seconds bilateral lower extremities: Delayed capillary refill indicates peripheral perfusion impairment. In combination with edema and erythema, this suggests vascular compromise or ischemia, increasing risk for tissue damage or necrosis. Monitoring perfusion is crucial for timely interventions and to prevent limb-threatening complications.

• Body circumference: Right calf 16.5 in (41.9 cm); left calf 17.25 in (43.8 cm): Asymmetry in calf circumference suggests localized edema, which may indicate deep vein thrombosis (DVT) or progression of cellulitis. Increasing leg size warrants prompt assessment to rule out thrombotic events. Timely attention is required to prevent complications such as pulmonary embolism.