Nursing Diagnosis Essay -- Clinical Reasoning Cycle

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 l evel of 33 were the abnormal labs. After a thorough examination, J.P. was diagnosed with a deep vein thrombosis (DVT). â€Å"DVT develops most often in the legs but can occur also in the upper arms†¦Ã¢â‚¬  (Ignatavicius & Workman, 2013). Due t... ...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.