My patients’ initial is R, G M and a 75-year-old female who lives with her son. She is divorced from husband. Her cultural identity is Anglo Saxon American who believes in family and the solidarity that involve in it. She belongs to the Erikson final stage of Ego integrity vs Despair. Her behavior that she portrayed to me showed that she felt successful as a happily divorced woman with a son. Although she has a son who is able to take care of her, she decided to go and stay with her friend in recovery who is a retired Nurse. She does not seem to be religious because when the chaplain walked into her room, she suggested to him that she likes to be alone and sleep, but as time went, she requested to have a discussion with a chaplain. However,
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She said that she had surgery before on her right knee and as a result, she knew she was allergic to codeine. Now, she has a left hip surgery and hope with the treatment her pain will subside. She states some of the medication that she is taking and the purpose. She is at risk for acute pain injury, bleeding, infection, impaired skin integrity, imbalanced nutrition, impaired gas exchange, self-care deficit, urinary retention, ineffective breathing pattern, powerless and depressed.
Basic Explanation of Medical Diagnosis or Problem: Moreover, Miss R, G M came to the hospital and went to the Emergency room. She complained to the attending nurse of chronic left hip pain, sore, swelling and difficulty walking around her house. She explained to the nurse that she took ibuprofen but she was still feeling pain. Similar, Foundation of Nursing states that osteoarthritis cause inflammation of joints, resulting in pain and limited joint mobility. It also cause joint tenderness …show more content…
I will assess for dyspnea (feeling breathless), orthopnea, bradypnia, tachypnea, abnormal breathing pattern (e.g., rate, rhythm, depth), prolonged expiration phases, pursed-lip breathing, decrease in minute ventilation, vital capacity, decrease in inspiratory/expiratory pressure, use of accessory muscles to breathe, use of the three-point position, altered chest excursion, paradoxical breathing patterns, nasal flaring (grunting), increase in anterior-posterior diameter. I will assess for concomitant pain/discomfort and note any emotional response. Next, I will also assess for any degree of sensory and cognitive impairment, use of coping skills, and support systems. I will determine the level of commitment and expectations for change and congruency of expectations with desires. I noted the degree of involvement in activities and relationships with others. I will identify spiritual beliefs and cultural values that influence sense of hope and connectedness and give meaning to life. I will assess about patient’s perception of the current state and expectations/goals for the future (e.g., general well-being, prosperity, independence). I will determine the current physical condition of patient/significant other. I review familiar and social history to identify past situations (e.g.,
She said that she had surgery before on her right knee and as a result, she knew she was allergic to codeine. Now, she has a left hip surgery and hope with the treatment her pain will subside. She states some of the medication that she is taking and the purpose. She is at risk for acute pain injury, bleeding, infection, impaired skin integrity, imbalanced nutrition, impaired gas exchange, self-care deficit, urinary retention, ineffective breathing pattern, powerless and depressed.
Basic Explanation of Medical Diagnosis or Problem: Moreover, Miss R, G M came to the hospital and went to the Emergency room. She complained to the attending nurse of chronic left hip pain, sore, swelling and difficulty walking around her house. She explained to the nurse that she took ibuprofen but she was still feeling pain. Similar, Foundation of Nursing states that osteoarthritis cause inflammation of joints, resulting in pain and limited joint mobility. It also cause joint tenderness …show more content…
I will assess for dyspnea (feeling breathless), orthopnea, bradypnia, tachypnea, abnormal breathing pattern (e.g., rate, rhythm, depth), prolonged expiration phases, pursed-lip breathing, decrease in minute ventilation, vital capacity, decrease in inspiratory/expiratory pressure, use of accessory muscles to breathe, use of the three-point position, altered chest excursion, paradoxical breathing patterns, nasal flaring (grunting), increase in anterior-posterior diameter. I will assess for concomitant pain/discomfort and note any emotional response. Next, I will also assess for any degree of sensory and cognitive impairment, use of coping skills, and support systems. I will determine the level of commitment and expectations for change and congruency of expectations with desires. I noted the degree of involvement in activities and relationships with others. I will identify spiritual beliefs and cultural values that influence sense of hope and connectedness and give meaning to life. I will assess about patient’s perception of the current state and expectations/goals for the future (e.g., general well-being, prosperity, independence). I will determine the current physical condition of patient/significant other. I review familiar and social history to identify past situations (e.g.,