Nursing Diagnosis Essay

1463 words - 6 pages

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 to the progression and status of J.P.’s current diagnosis, the doctor’s found it necessary to perform an above the knee amputation immediately. After surgery, her doctors prescribed several new medications to add to the list of medicines that she was taken at home.

Ineffective peripheral perfusion related to impaired arterial circulation was the highest priority diagnosis for this patient. The patient had a circulation issue related to a thrombosis that impaired the delivery of oxygen to the lower extremity. A client with a deep vein thrombosis may present to the clinic or emergency room with a red, warm, swollen calf (Ackley & Ladwig, 2010). In this case, the perfusion of the tissue in her lower, right leg was inhibited to such a large degree that her leg required amputation above the knee.
Another NANDA diagnosis for the patient was Infection related to MRSA and a high white blood cell count (Ackley & Ladwig, 2010). This diagnosis became the second highest priority. Methacillin Resistant Staphylococcus Aureus is an infection that a patient may develop many times in the hospital setting. It is resistant to certain antibiotics, thus making it very difficult to treat. MRSA is also highly contagious. A white...

Find Another Essay On Nursing Diagnosis

How to Choose the Correct Education, Training, and Certification for Various Nursing Career Paths

1171 words - 5 pages injuries, diagnosing and treating human ailments, and advocating patient care, including the patient's family, community, and others. Nursing careers offer a broad variety of roles with heavy responsibilities. Nurses work alongside physicians to address day-to-day patient situations within the health care system. The physician mainly makes the key decisions regarding the diagnosis, treatment, and medication per the patient's situation. Nurses ensure

The Nursing Shortage Essay

2473 words - 10 pages of Health and Human Services, it is estimated that “more than a million new and replacement nurses will be needed over the next decade” (Diagnosis: Critical). A chronic nursing shortage has been a reoccurring problem that impacts the future of our health care system and, even more so, the future quality of long-term care in this country. Currently, there are several federal and state initiatives, organizations, and agencies dedicated to

Concept Comparison and Analysis

1758 words - 7 pages Concept Comparison and Analysis Across Theories Nursing is a science that has many theories to support the beliefs and clinical practice of the profession. One core concept prevalent in many nursing theories is caring. Theorist Jean Watson and Madeleine Leininger are both nursing theorists who developed theories around caring and nursing. The subject of discussion in this paper is the comparison and analysis of the concept definitions of Jean

Clinical Research Nursing

993 words - 4 pages Nurses are primarily responsible for the diagnosis and treatment of diverse populations; however, there are different nursing career paths beyond these traditional functions. A clinical research nurse (CRN) conducts scientific research within the context of modern medicine. Medical research consists involves the study of diseases, and the creation of new treatments or drug to treat them. Clinical research nurses may contribute to these

Identify the stages of the Nursing Process and the skills essential to the Nursing Process

1952 words - 8 pages The nursing process is a five stage systematic framework, and based on the problem solving approach; it forms the foundation for nursing practice to facilitate focussed, individualised care planning for patients (Yildirim and Ozkahraman 2011). This assignment will serve to identify the five stages of the nursing process: Assessment, Nursing Diagnosis, Planning, Implementation and Evaluation. The skills: Communication, Observation, Critical

Nursing: Providing The Best Possible Care For Patients

1605 words - 6 pages Personal Nursing Philosophy Nursing has developed from its original roots, to become a personal philosophy to those who practice it. This paper describes my personal philosophy of nursing that I plan to practice in my own personal career. I believe that nursing is founded on the principles of it being a helping process with a focus on interpersonal relationships between a nurse and someone else. Nursing not only involves treating an illness

Tradtion to Evidence Based Practice This essay illistrates historical developments in nursing research

1341 words - 5 pages Tradition to Evidence Based PracticeYou are the nurse caring for Mr. Smith who has a diagnosis of neutropenia. The family brings him an arrangement of live plants. A sign on Mr. Smith's door lists precautions; one states no live plants. The family asks why and you explain that the soil has bacteria and due to Mr. Smith's low white cell count, he is susceptible to infection. The family wonders how the bacteria in the soil can cause an infection

Dr. Hildegard E. Peplau and Her Theory

2195 words - 9 pages every stage of my nursing practice. For instance, my initial nursing assessments of the patient will coincide with the orientation phase of Dr. Pepalu’s theory. My nursing diagnosis and planning as well as implementation will correspond with the theory’s exploitation phase; and lastly, evaluation with the resolution phase. Application of theory in My Nursing Practice: This theory would be useful with every newly diagnosed patients and their family

Nursing Care Plan: Impaired Parenting

1393 words - 6 pages Impaired Parenting is a nursing diagnosis that should be considered for all parents who are having a child. There are many classes available to new parents that can be taken before childbirth takes place. These classes will inform parents how to take care of their newborn child, as well as, mentally prepare each family member what their role will be with the birth of their new child. The National Center on Shaken Baby Syndrome says that in 2003

The Five Phases of the Nursing Process

1380 words - 6 pages as well as his problems. This will later lead to the identification of risks and the type of diagnosis. For the diagnosis to help the nursing care to be effective it is very important that all judgments, decisions and assessments are as accurate as possible also making the next phase, planning, easier. This phase works hand in hand with the diagnosis phase as the nurse has to plan the actions to be taken after the diagnoses are done. Again

Registered Nursing - Gastroenterology

1625 words - 7 pages patients makes diagnosis rather difficult. A complete report of the patient’s history and an adequate physical examination are required in order to retrieve as much information possible to construct a prognosis. Although this is routinely done by the admitting gastroenterologist, a nursing assessment must be completed as well (Heiserman). Registered nurses specializing in the gastroenterology field are needed to interview the patients of their

Similar Essays

Nursing Diagnosis Essay

1149 words - 5 pages Nursing Diagnosis I Nursing Diagnosis I for Patient R.M. is ineffective airway clearance related to retained secretions. This is evidenced by a weak unproductive cough and by both objective and subjective data. Objective data includes diagnosis of pneumonia, functional decline, and dyspnea. Subjective data include the patient’s complaints of feeling short of breath, even with assistance with basic ADLs. This is a crucial nursing diagnosis as

Nursing Informatics Theory Essay

1180 words - 5 pages Nursing informatics is a branch of nursing or area of specialty that concentrates on finding ways to improve data management and communication in nursing with the sole objective of improving efficiency, reduction of health costs, and enhancement of the quality of patient care (Murphy, 2010). It is also described as a growing area of nursing specialty that combines computer science, information technology, and nursing science in the management

Ernestine Wiedenbach's Contribution To The Development Of Clinical Nursing Practice

976 words - 4 pages whether they will need help. If they need help, then this is addressed in the nursing care plan and will go through the stages of the nursing process. Nursing diagnosis' in care plans are an excellent representation of the use of a need for help. The nursing diagnosis of the “Feeding Self-care deficit”(Ackley& Ladwig, 2008), for example, when diagnosised for a patient in their care plan has been assessed by the nurse. The nurse has assessed and come

Nursing Process Discipline And Independent Nursing

1565 words - 6 pages discipline helped to define the nursing process and its effect on nursing today. Nursing Discipline Theory as it Relates to Nursing and the Nursing Process Ida Jean Orlando’s nursing discipline theory is recognized as a theory that helped establish today’s actual nursing process of assessment, diagnosis, outcomes/planning, implementation, and evaluation. The nursing process, as stated by the American Nurses Association (2009) is: “The common