J.P., a 58 year old female, presents to the Emergency Room on March 18th. She has a past medical history of cervical cancer, atheroembolism of the left lower extremity, fistula of the vagina, peripheral vascular disease, neuropathy, glaucoma, GERD, depression, hypertension, chronic kidney disease, and sickle cell anemia. She complains of right lower extremity pain accompanied by fatigue, a decreased appetite, increased work of breathing, burning on urination, and decreased urine output for three days. On admission, a complete physical assessment was performed along with a blood and metabolic panel. The assessment revealed many positive and negative findings. J.P. was positive for dyspnea and a productive cough. She also was positive for dysuria and hematuria, but negative for flank pain. After close examination of her integumentary and musculoskeletal system, the examiner discovered a shiny firm shin on the right lower extremity with +2 edema complemented by severe pain. A set of baseline vitals were also performed revealing a blood pressure of 124/80, pulse of 87 beats per minute, oxygen saturation of 99%, temperature of 97.3 degrees Fahrenheit, and respiration of 12 breaths per minute. The blood and metabolic panel exposed several abnormal labs. A red blood cell count of 3.99, white blood cell count of 22.5, hemoglobin of 10.9, hematocrit of 33.7%, sodium level of 13, potassium level of 3.1, carbon dioxide level of 10, creatinine level of 3.24, glucose level of 200, and a BUN level of 33 were the abnormal labs. After a thorough examination, J.P. was diagnosed with a deep vein thrombosis (DVT). “DVT develops most often in the legs but can occur also in the upper arms…” (Ignatavicius & Workman, 2013). Due t... ... middle of paper ... ...diagnoses that cause physical pain, but also problems that can cause emotional, spiritual, and psychosocial trauma. After the implementation of the stated interventions, the patient made physical and emotional progress towards the aforementioned goals. The above goals were not only met, but exceeded expectations of the patient and the nurses who provided care. Works Cited Ackley, B. & Ladwig, G. (2010) Nursing diagnosis handbook:an evidence based guide to planning care. Maryland Heights, MO: Mosbey. Ignatavicius, D. D., & Workman, M. L. (2013). Care of Intraoperative Patients. Medical-surgical nursing: patient-centered collaborative care (7th ed.). St. Louis: Elsevier. Taylor, C. (2011). Introduction to Nursing. Fundamentals of nursing: the art and science of nursing care (7th ed.). Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins.
Practice. In P. A. Potter, & A. G. (7th ed.) Perry, Fundamentals of Nursing (pp. 215-324). Saint Louis MO: Mosby-Elsevier.
The nurse is creating a four-column plan of care for a client. For which areas should the nurse prepare to document when creating this care plan?
This is an 84-year-old Arabic patient with a significant past medical history of hypertension, hyperlipidemia, and hypothyroidism. She also has a question of osteoarthritis and gout. She came to the emergency room with pain in her right ankle and foot extending into her leg. She had difficulty in ambulating. She had no chest pain, shortness of breath or other significant symptoms. Her past medical history she has a history of hypertension, as I noted, congestive heart failure and hyperlipidemia. Her initial diagnostic testing revealed a white count of 12.4 with uric acid of 5.5, creatinine was 2.36 however her previous creatinine was abnormal at 1.43 but that was from 3 years prior. She had a CAT scan of the foot which showed an osteochondral
Lina was lying in bed, with head of bed elevated at about 50 degrees. Awake and alert, making noises and yelling when BP is being taken. She is receiving oxygen via nasal cannula at 3 lpm; none apparent respiratory or any other type of distress. Her skin is intact; however I noticed right hand swelling, possible IV infiltration, she has an IV in the affected hand that I did not see during my previous visit since she was wearing meetings. Hypoactive bowel sound, abdomen soft-non-tender. She continues with a Central line to right
Potter, P. A., & Perry, A. G. (2013). Fundamentals of nursing (8th ed.). St. Louis, MO: Mosby.
Ladwig, G. B., Ackley, B. J., & Makic Flynn, M. B. (2014). Mosby's Guide to Nursing Diagnosis (Early Diagnosis in Cancer). St. Louis, Missouri: Elsevier Health Sciences.
Potter, P.A,& Perry, A. G. (2009).Fundamentals of Nursing (8th ed.). Wileyblackwellpublishing, A Company of John Wiley and sons, Canada.
Healthy-looking young 20-year-old female no obvious things to note on observation. She essentially had full cervical range of motion, normal upper extremity range of motion and strength. Palpation had exquisite tenderness along the upper
Spark Ralph, S. & Taylor, C. M. (2011). Nursing diagnosis reference manual (8th ed.). Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins.
His blood glucose level indicated 10mmol/L. Mr Harry Bright was evaluated with PQRST assessment and was administered sublingual nitro-glycerine spray and morphine for his chest pain. The quality of his pain is in his chest and the region of pain was radiating down his arm and jaws. The pain started at 4 or 5 minutes after the nursing handover and the severity of the pain was 6 out of 10. During his episode of chest pain, the medical officer was contacted to inform his chest pain and to confirm his medication prescribed. Then, the patient mentioned pain in his right groin where neurovascular observation was performed. The affect limb appeared pallor, polar, paraesthesia, and pulselessness and the patient stated numb, pin and needle sensation. The patient was repositioned with his head of bed elevation below 30 degrees due to discomfort and his metformin tablet was not administered. His puncture site have only minimal amount of oozing, no swelling or haematoma. My only concerns is that he may have an occlusion vessel in his limb based on the observation and assessment
You arrive on scene at a brown house with lights on and door open. To a patient that skin is pink warm (normal). Blood pressure 112/76 and pulse 61. Pupils are Equal and reactive, patent airway, says hurts to breath in once in a while. He says the pain has been radiating from his back, then side, then inner thigh/abdomen area for 2 weeks or so. No vomiting or nausea, no allergies, takes vitamins every day, fish oil. No meds, no pertinent past history, ate a tuna sandwich earlier that day with some red bull. The pain has just been generally getting worse for the past 2 weeks. He thought he pulled a muscle during
Based on the medical report dated 12/07/16 by Dr. Sunadresan, the patient presents with increasing back pain, radiating to both knees. Past medical history is significant also for hypertension, for which she takes lisinopril. She also takes Tylenol with codeine.
art and science of nursing care (6th ed). Philadelphia, PA, Lippincott Williams & Wilkins, a Wolter Kluwer business.
Back with no tenderness over her kidney area. She does have a scar in her low back. Scar is surrounded by some blotchy redness, but the patient states this always looks like this. She does have pain to palpation above the scarred area and her low back. She has decreased range of motion of her low back, in general. Flexion however, causes significant pain and she is reluctant to do this. She has no pain when flexing her neck.
Nursing Diagnosis 1 The family’s primary nursing diagnosis is interrupted family processes related to the shift in health status of a family member as manifested by decrease in mutual support and alteration in family satisfaction (Ackley & Ladwig, 2014). Outcomes 1 Over the next 5 days each member of the family will explain a way that they will learn to express their feelings freely and appropriately. First, each member of the family will verbalize the understanding of the condition and treatment regimen they are dealing with in the family. Over the next 2 weeks each member of the family will have successfully expressed their feelings, when needed to, towards the stress of dealing with the shift in health status of their family member. By doing this, the family