Scenario

Karl is a 45 year old obese ( 250 lbs 5ft 6 inches tall man). He entered the nurse’s office
complaining of pain and tenderness in his right calf by three days. He said that he is
experiencing pain and difficulty walking. Karl is self-employ is as an accounting software
developer for small business; his office is located at his house. He sits at his computer for
upwards of 10 hours a day. He is unmarried and eats out more than six times a week, usually
at the fast food palace which is just about a ten minute walk from his office. Karl usually
chooses to drive to the outlets and he says walking cause pain, burning and fatigue in his legs.

On evenings Karl usually eats dinner in front of a big screen computer in his bedroom and
sometimes falls asleep in his chair there. His medical history includes a coronary artery
bypass graft (CABG) five years ago for angina, complicated postoperatively by a pulmonary
embolus. However, he has not had any problems since then. The nurse’s physical assessment
reveals his right calf is swollen, slightly flushed, red warm and tender on palpation. His right
calf measures 42cm at 20am above the ankles. His left calf is 34.5cm at the same location.
Homan’s sign is positive for pain in the right calf only. He denies numbness, tingling or loss
of mobility in either extremity.

OBJECTIVES

1. Document Objective Data.

2. Document Subjective Data.
3. List possible nursing diagnoses.
4. List possible nursing interventions.
5. Wellness Diagnosis and interventions
 KARL’S ASSESSMENT
The examination room was made comfortable and the lighting was ideal for him
during procedure. On inspection of legs- the colour, size, shape, symmetry were
observed. The texture, turgor, size, shape and degree of tenderness were
palpated using the finger pads with light and deep palpations. The dorsal aspect
of the hand was used to determine any increase in temperature at the calf area.
The pulse sites of the lower limbs were palpated and auscultated using the
stethoscope. The measuring tape was used to measure the size of each calf to
record edema.

Homan’s test was then performed: Karl’s knee was in an extended position and
the examiner forcefully dorsiflexed his ankle. A positive sign is indicated when
pain is experienced in the popliteal region and the calf is elicited as the foot is
dorsiflexed.

The results were recorded in the objective and subjective data.

DATA BASE FORM

NAME: Karl John Smith

AGE: 45 Years Old

SEX: Male

D.O.B: 6th April 1971

ADDRESS: #123 Five Stone Street, North Valsayn

RELIGION: Christian ETHNIC GROUP: Mixed MARITAL STATUS: Single

NEXT OF KIN: Joann Smith-Clarke (Sister) ADDRESS: #2 Bayview Drive, Chaguaramas

VITAL SIGNS: B/P138/79 T 36.9°C P83b.p.m R22 WT250lbs HT5ft 6inches

URINALYSIS: NAD

PATIENT STATED REASON FOR ADMISSION: Complained of pain and tenderness in

his right calf for three days. It causes pain and difficulty walking. Walking causes pain,
burning and fatigue in his legs.

MEDICAL DIAGNOSIS/PRECIPITATING FACTORS: NIL

EXISTING HEALTH PROBLEMS: NIL

MEDICATIONS: NIL

PERSONAL AND SOCIAL HISTORY

Client lives in an owner-occupied, high rise building with four bedrooms and one occupant.
All amenities (pipe borne water, flushing toiler and electricity). Garbage disposal is by truck
twice a week.

PAST ILLNESSES: Coronary artery bypass graft for angina five years ago complicated
postoperatively by a pulmonary embolus.

PREVIOUS HOSPITILIZATIONS: West Shore (2011) for 15 days

ACTIVITIES OF DAILY LIVING

Mr. Karl is independent in achieving the activities of daily living such as meeting hygiene
needs, mobility, dressing, feeding and toileting.

SLEEPING PATTERNS: 3-4 hours a night

SYSTEMS REVIEW

VISION: Wears glasses or sometimes contacts in both eyes

HEARING: No difficulty

COMMUNICATIONS: No difficulty, Speaks English, Spanish and French fluently

RESPIRATORY: No difficulty

CIRCULATORY: Calf pain

GASTROINTESTIONAL: Appetite is good, no special diet, eats twice a day, no dislikes,

drinks 5-6 big 120z glasses of water a day, gained 40 lbs within 9 months, no difficulty
passing stool (once a day), no use of laxatives.

URINARY: No difficulty, Colour of Urine: Amber

MUSCULO SKELETAL: Pain

MOBILITY: No difficulty

NEUROLOGICAL: No difficulty

SKIN: No abnormality

REPRODUCTIVE: No abnormality

History taken by: DENEILLE HARPER Date: 30th November, 2016

Signature: DHarper(RN)

OBJECTIVE DATA
Upon assessment of Karl’s right calf, it was observed to be swollen, slightly flushed, red,
warm and tender on palpation. The right calf was measured to be 42cm at 20 cm above the
ankles while the left calf measured to be 34.5cm at the same location. Homan’s sign was
positive for pain in the right calf only. Full range of motion of all joints, with no pain,
tenderness, clicking or crepitus in the left leg. Nil lesions, scars, rashes were observed on
upper or lower extremities. Full smooth ROM against gravity and resistance.

Upon physical assessment, the objective data found were:

 Weight 250lbs
 Right calf swollen, slightly flushed, red, warm and tender on palpation
 Right calf = 42cm as compared to Left calf = 34.5cm
 Homan’s sign positive in right calf only
 Facial grimacing

SUBJECTIVE DATA
Mr. Karl Smith complained of pain and tenderness in his right calf for three days. Has
difficulty in walking which causes severe pain, burning and fatigue in his leg. On a pain scale
of 1-10 the pain is an 8. He is not physically active, sits at the computer for ten hours a day as
an accounting software developer. Eats out more than six times a week and drives to the fast
food outlet that’s ten minutes away. He had a history of a coronary bypass graft 5 years ago
complicated postoperatively by a pulmonary embolus. No history of smoking or alcohol use.
Client voiced no complaints of numbness, tingling or loss of mobility in either extremity.

Verbalized by Karl….

 Pain and tenderness in right calf x 3/7

 Difficulty walking
 Walking causes pain, burning and fatigue in legs
 Nil numbness, burning and loss of mobility in either legs
 Not married
 Eats fast food more than six times a week.
 Drives to the fast food outlet that’s ten minutes away
DIAGNOSIS AND INTERVENTION
Nursing Diagnosis: Risk for myocardial infarction related to patient obesity, diet and past
history

Nursing Interventions

 Assess client choices (eating habits, exercises, socializing etc.)

 Discuss with client the potential of having another heart attack by enforcing his
previous knowledge
 Encourage client to check and documents his calories intake everyday
 Develop a well balance diet plan consisting of the six-food group, that will encourage
him to make the right food choices
 Encourage client to hire a personal chef that can prevent him from buying fast food
 Recommend client to hire personal fitness trainer, join a gym, dancing class, walking,
etc.)
 Recommend client to weigh watchers groups online or community groups to help
advised him on healthy tips

Nursing Diagnosis: Risk for situational low self- esteem related to lack of socialization
Nursing Interventions

 Recommend client to join dating sites, keep in contact on facebook to engage in

socialization
 Encourage client to have guy’s night or dine out with friends to build self esteem
 Encourage client to have fun time with family, friends or someone he cares for
through skype, video chat etc. to help enhance socialization skills
 Recommend client to clubs (cricket, golf, dance, swimming, cards, pool, cars, etc.) to
help boost social interaction

Wellness Diagnosis Plan

 Old views

vs
Readiness to Modify Health

WELLNESS DIAGNOSIS: Readiness for enhanced lifestyle

INTERVENTIONS:

1. Recommend that Mr Karl use a massage chair to promote circulation and elevate his
foot while he sits for his long work hours.
2. Encourage Mr Karl to walk to the fast food outlet since it is 10minutes away.
3. Discuss/educate with Mr Karl the importance of incorporating simple daily exercise
into his schedule.
4. Recommend a Personal Trainer for enhance daily exercise routine
5. Recommend body massages at least once a month.

WELLNESS DIAGNOSIS: Readiness for enhanced nutrition

INTERVENTIONS:

1. Discuss current eating patterns by having Mr Karl state what, when and where he eats.
2. Discuss/educate Mr Karl about the importance of a proper well balanced diet/meal.
3. Develop a meal plan with a well-balanced diet, reduced calories and reduced fat,
therefore encouraging him to make healthy choices while purchasing food.
4. Suggest hired (chef/ healthy delivery lunches)
5. Encourage him to attend weight control programs held at the community health
centre.

WELLNESS DIAGNOSIS: Readiness for enhanced knowledge

INTERVENTIONS:

1. Assess Mr Karl’s current health status (restrictions, problems, personal habits etc.)
2. Assess/discuss his lifestyle and choices by discussion.
3. Discuss with him his potential for developing chronic diseases (diabetes,
hypertension), due to his current health status.
4. Introduce him to online soft copies books about chronic diseases
5. Converse his risk for having Deep Vein Thrombosis due to his complaint.
 6. Discuss his familiarity with technology, so that it can be a source of learning.

WELLNESS DIAGNOSIS: Readiness for enhanced socialization and interaction

INTERVENTIONS:

1. Encourage Karl to join age appropriate programs where interaction is included eg.
Programmes or activities at the health centre.
2. Encourage Karl to go out and socialize after work.
3. Introduce Karl to online dating and chatting
4. Suggest community charity and mentoring youths

From sedentary to mobility

Mission Accomplish!