JP, a 58-year-old woman, presents 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, chronic kidney disease, and sickle cell disease. He complains of pain in the right lower extremity accompanied by fatigue, decreased appetite, increased work of breathing, burning during urination, and decreased urine output for three days. Upon admission, a complete physical assessment was performed along with a blood and metabolic panel. The evaluation revealed many positive and negative findings. 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 systems, the examiner discovered a shiny, firm tibia on the right lower extremity with +2 edema accompanied by severe pain. A series of basic vital signs were also performed which revealed 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 . The blood and metabolic panel revealed several abnormal tests. A red blood cell count of 3.99, a white blood cell count of 22.5, a hemoglobin 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. After a thorough examination, JP was diagnosed with deep vein thrombosis (DVT). “DVT most often develops in the legs but can also occur in the upper arms…” (Ignatavicius & Workman, 2013). Due to... half of the document......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 towards the above-mentioned goals. The above objectives were not only achieved, but exceeded the expectations of the patient and the nurses who provided the 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). 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.
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