The nurse is caring for Jose Crixell, an 85-year-old client who has been admitted to the hospital for
cellulitis of his lower right leg secondary to a puncture wound he experienced after a fall at home.
Jose lives with his daughter and her family since his wife died 2 years ago. The client a history of
hypertension and using a cane for stability but is otherwise healthy. During shift report, the off going
nurse reported Jose’s vital signs to be “within normal limits”; the wound is open and has a scant
serosanguinous drainage. The wound is approximately 1 cm round on the lateral side of his lower
right leg. The unlicensed assistive personnel (UAP) reports Jose’s current vital signs are as follows:
Blood Pressure 165/94, Pulse 101; Respiratory Rate 28, Temperature 101.8°F. The client reports
“feeling worse” now compared to previously in the day and generally feeling weak. He reports
feeling more pain in his lower right leg, 5/10 on pain scale, and feels his leg is more swollen and
red. The client has an antipyretic ordered to treat fever and pain in addition to the IV antibiotics to
treat the infection. The last time Jose had the antipyretic acetaminophen was 1200; it is now 1800.
The prescription is to administer acetaminophen 650 mg every 4 hr as needed for pain or fever.
The antibiotic is due to be administered next at 2200. Jose normally takes an antihypertensive
medication once daily but takes no other routine medications; he had the antihypertensive at 0900