Patient: B.A. Age: 57 Isolation: Contact- MRSA Allergies: Sulfa 0800 Assessment
ID: 243134 • Letter: P
Question
Patient: B.A. Age: 57
Isolation: Contact- MRSA
Allergies: Sulfa
0800 Assessment
HPI
B.A. is a 57 yo male with a history of uncontrolled Diabetes Type 2 diagnosed in 2008. Pt was admitted with c/o increased numbness and tingling, and decreased sensation in his lower extremities x 4days. Pt reports that he noticed a reddened swollen area on his right leg that appears to be spreading.
Physical Examination
BP: 134/86 Lt arm sitting
HR: 96 regular rate and rhythm
R: 18/min
SPO2: 97%
Wt: 160lbs
Ht: 5’5”
Bilateral radial pulses 2+/4, Rt dorsalis pedis pulse 1+/4. The right calf is twice the size of the left one. The skin on the rt calf is erythematous with 2+ pitting edema.
IV Access: 20 gauge Lt AC PIV infusing 0.9 NS @ 100ml/hr. Site has some mild erythema and swelling. Pt has pain 4/10 at IV site
Intake: 50% of breakfast (pancakes and bacon), 200ml of juice
Urine Output: 180ml straw colored urine
Diagnostics
Ultrasound: DVT in rt leg
Develop a nursing diagnosis and plan for a patient using the above information. Write what parts of the information provided go in subjective or objective section.
Explanation / Answer
Patient Name: B.A Age: 57 years
SUBJECTIVE DATA:- 57 Years old male patient came to the hospital with the following complains:
OBJECTIVE DATA:-
NURSING DIAGNOSIS:
GOAL: To maintain skin integrity and skin sensation of patient.
PLAN:
2- Acute Pain to the patient at IV site due to cannulization.
GOAL: To reduce the pain of the patient.
PLAN:-
3- Risk of infection related to wound on right leg.
GOAL:- To reduce the risk of infection in patient.
PLAN:-