Concept Map Critical Thinking PDF

Preview

Summary

n/a...

Description

Chief Complaint: -The patient states she has “pain in her upper back” today.

Meds: -The patient states that she takes a couple of ibuprofens to help with her pain

Labs & Diagnostic Tests: -Last set of blood work was done 11 years ago -Patient has never had osteoporosis screenings. Nursing Diagnosis 1: -Impaired physical mobility related to pain.

Nursing Diagnosis 2: -Acute pain due to musculoskeletal problems.

Nursing Diagnosis 3: -Acute pain r/t additional fractures r/t osteoporosis.

Patient Teaching: Assessment Findings:

-Instruct client to stop smoking

-Patient describes pain as “sharp and knifelike”.

-Instruct client on the risk factors of her continuing to smoke

-Patient went through menopause at age 47

-Teach patient the importance of exercising at least 20 minutes a day

-tenderness upon deep palpation over the spinous process of T7. -No masses or tenderness palpated around the tender area.

-Teach the patient the importance of yearly physicals and osteoporosis screenings.

No visible masses, skin changes, or erythema were noted. -Neurological exam was intact.

Current Symptoms:

Patient Characteristics:

-Pain in lower back; patient expresses that it is a 6 on a 0 to 10 pain scale.

-Name is M.S. -72-years old female

-tenderness upon deep palpation

-States she “doesn’t like doctors” and has not been to the clinic in 11 years. -Patient is Caucasian. Medical History: Risk Factors: Patient states she has been “smoking 1 or two packs of cigarettes per day since she was 17 years old”. -Patient is at risk for hormone imbalance due to not getting hormone replacement therapy after menopause.

_Mother and grandmother were diagnosed with osteoporosis in their early 50s. -no prior osteoporosis screenings -last labs and physical were 11 years ago Possible Medical Diagnoses:...