Nursing Diagnosis - 1441 Words

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†¦show more content†¦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 blood cell count that is above 10.8 is considered elevated; J.P.’s count was 22.4 (Jarvis, 2012). Due to the thrombosis, as well as having the above knee leg amputation, a diagnosis of Impaired Comfort related to altered health status and chronic pain, became a medium priority (Ackley Ladwig, 2010). A patient that suffers an amputation can experienceShow MoreRelatedNursing Diagnosis875 Words   |  4 PagesNursing 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. 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