Patho diagram and assessment help please!!

lccougar02 · Oct 7, 2005

I have to do a patho diagram for nursing school and i wanna make sure everything related to eachother. Can an educator please help me? I can email it to you bc it has a lot of arrows.

~Janine

Also, I have an assessment written, can someone check it over and see if its good?

Ms. H was admitted to Heartland of Mentor on because Ms. H claims, "the doctor said I wasn't allowed to be alone." I discovered from documentation that her son was worried about Ms. H's well-being living alone; therefore she was transferred to Heartland to be a resident.

0800 Female patient supine in recliner chair, eyes open, watching television.

Vital signs Temp: 97.9ºF, Pulse 62, Resp 22, BP 130/60

Neuro a&o x 3. Pupils equal and round. Obeys simple commands. Smiles when greeted.

Cardiovascular Apical irregular 62. Radial pulses present +2. Pedal pulses +1. Left and right upper extremities warm, no edema. Right and left lower legs red, warm, tight, 2+ pitting edema. c/o pain in right calf area. Cap refill on upper body

Respirations Breath sounds clear in upper lobes, diminished in bases bilaterally. Chest rise symmetrical, SOB upon exertion. Rate 22. No cough present. Nailbeds pink. Mucous membranes moist and pink.

GI Normoactive bowel sounds x4 quadrants. Abdomen soft and round. Incontinent x1 of soft brown stool.

GU Pt ambulates with walker to bathroom & voids clear yellow urine.

Integument Skin warm, dry, smooth on body with exception to the lower legs bilaterally, which are red, warm, dry, scaly, and rough.

MS Pt states, "I have numbness and pain in my joint of my left hand." Pt able to do ROM on all extremities with exception of pain to right calf upon flexion of right foot. Nurse practioner aware.

Pain Pain 4/10 on right calf, 1/10 of left hand joint.

Psychosocial Pt easy to work with and unhappy to see me go.

1030 Pt leaves Heartland of Mentor via w/c with legs elevated to go on bus trip with authorized personnel.