Hi there. I am new to the boards. Already posted in Introduction and greetings!!~
I am working on a case study for class. I have this patient with the following:
70 y/o female c/o severe abd pain, N/V, she thinks there may be white spots all over in her mouth. She feels miserable, lives alone, lost about 20 lbs over past 3 months, pain in legs, tired, unable to do much, weak, tired all the time. Pt states history: HTN, "maybe" kidney problems. She urinates sometimes (pain when she does), admits to malodorous urine.
I must list numerous nursing diagnosis, vitamins she is deficient in, nursing interventions, diagnostic procedures to be done, anticipated Dr orders (diet, meds, labs, activites), Meds I would anticipate her being on, etc....
In addition I have to create a concept map and care plan.
I was just wondering what all of you think she has? I am working on this now and thought who better to ask than all of you.....please let me know what you think......
this one will keep me busy for a while....
Thanks a million for any input.
Nov 25, '05
Quote from NJNursing
And the pain in the legs could also be a DVT from being sedentary and often laying/sitting around for long periods of time. And I also agree about the PAD/PVD.
But we need to examine the 5th vital sign. In regards to c/o "abd pain" and "leg pain" a more in depth analysis of the pain is required. Are there precipitating factors, does the abdominal pain or leg occur after certain activities such as walking or moving a certain way or do certain activities make it worse or better. The quality of the pain, such as aching, stabbing, cramping, burning, tearing, pulling, etc. The intensity such as 1/10 or 10/10. Is it intermittent or intractable. Onset and duration. Does it radiate. Location, for instance epigastric area, RUQ, calf pain. What provides relief, for instance does elevating the legs increase or decrease the pain. Pattern of the pain, does leg pain occur after a certain amount of activity or when the abdominal pain occurs in relation to eating. Concomitant symptoms such as, for instance, pain from an inflammed gallbladder or kidney stone will frequently cause nausea or vomiting. Also is the abdominal pain or leg pain a new development or have they been dealing with this over a lengthy time span. Reaction to pain, some people exhibit very little non-verbal cues, while others are not only quite verbal, they will have facial grimaces, may be doubled over and rocking, basically people express pain differently based on numerous factors. What measures does the pt usually take in regards to pain relief. What is the patient's experience in regards to pain and beliefs about pain. How is the pain affecting or influcing the patient on a daily basis in regards to normal activity.
There are so many factors to consider when assessing pain. I'm sure I didn't mention them all. Also as a nurse are there prejudices and misconceptions in regards to pain that we may have that can affect how we treat/manage pain with our patients.
Last edit by DusktilDawn on Nov 25, '05