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Essay / Nursing diagnosis - 1434
JP, a 58-year-old woman, presented to the emergency room on March 18. She has a past medical history of cervical cancer, left lower extremity atheroembolism, vaginal fistula, peripheral vascular disease, neuropathy, glaucoma, GERD, depression, hypertension, kidney disease chronic and sickle cell anemia. She complains of pain in the right lower limb accompanied by fatigue, decreased appetite, increased work of breathing, burning when urinating and decreased urine output for three days. On admission, a complete physical assessment was performed as well as a blood and metabolic panel. The evaluation revealed many positive and negative results. JP was positive for dyspnea and productive cough. She was also positive for dysuria and hematuria, but negative for flank pain. After careful examination of his integumentary and musculoskeletal system, the examiner discovered a firm, shiny tibia in his right lower extremity with +2 edema complemented by severe pain. A basic set of vital signs was 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 respirations of 12 breaths per minute. Blood and metabolic panel revealed several abnormal labs. A red blood cell count of 3.99, a white blood cell count of 22.5, a hemoglobin level of 10.9, a hematocrit of 33.7%, a sodium level of 13, a potassium level of 3.1, a carbon dioxide level of 10, a creatinine level of 3.24, a glucose level of 200, and a BUN level of 33 were abnormal laboratory results. After a thorough examination, JP was diagnosed with deep vein thrombosis (DVT). “DVT most commonly develops in the legs but can also occur in the upper arms…” (Ignatavicius & Workman, 2013). Due to...... middle of paper ......diagnoses that cause physical pain, but also problems that can cause emotional, spiritual, and psychosocial trauma. After implementing the indicated interventions, the patient made physical and emotional progress toward the aforementioned goals. The above goals were not only achieved, but also exceeded the expectations of the patient and the nurses who provided the care. Works Cited Ackley, B. and Ladwig, G. (2010) Nursing diagnostic manual: an evidence-based guide to care planning. Maryland Heights, MO: Mosbey. Ignatavicius, DD and Workman, ML (2013). Intraoperative patient care. 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 (7th ed.). Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins.