University:
American Career College
Course:
NURS112 | Fundamentals of Nursing
Academic year:

2023
Views:

292

Pages:

1
Author:

Alma Stephenson

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. 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. No visible masses, skin changes, or e were noted. -Neurological exam was intact. Current Symptoms: Patient Characteristics: Pain in lower back; patient expresses hat it is a 6 on a 0 to 10 pain scale. -Name is M.S. Nursing Diagnosis 1: -72-years old female -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. -Teach the patient the importance of yearly physicals and osteoporosis screenings. tenderness upon deep palpation -States she “doesn’t like doctors” an not been to the clinic in 11 years. -Patient is Caucasian. Medical History: Risk Factors: Patient states she has been “smokin two packs of cigarettes per day since she was 17 years old”. _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: