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...