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Nurse’s Notes Q4: 0800: 62-year-old client brought to The nurse has reviewed the 0800 and 0900 nurse’s notes emergency department by spouse after and is planning care. tripping at home 6 hours ago. Right midfoot swollen with large amount of bruising on For each potential nursing intervention, specify if the toes and sides of foot. Less swelling on intervention is indicated or contraindicated for this client. ankle. No external bleeding or wounds. Reports pain 10/10 and unable to stand on Potential Intervention Indicated Contraindicated foot, unable to move without difficulty, increased pain with palpation of superior Assess level of pain. 0 aspect of foot. Able to move toes and dorsiflex foot, pedal pulse palpable, Teach to apply heat. O capillary refill delayed. Has history of Elevate the foot above hypertension, L meniscus repair 6 years ago, O 0 the level of the heart. hepatitis A as a child. VS: T 98.4.F (36.9.C), P 110, RR 18, BP 132/92, Oz sat 96%. Lungs Assess ability to clear. Alert and oriented to person, time, differentiate sharp and dull touch. place. Takes daily amlodipine 10 mg and benazepril 20 mg. Apply ice to swollen areas. 0900: X-ray of the foot indicates a nondisplaced fracture of second and third metatarsals. Able to move toes. Capillary refill 2 seconds. Pain rated at 8/10.

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