solved

Seeking Care due to Lower back pain for 2 weeks:
SUBJECTIVE: Pt is a 40-year-old woman who developed lower back pain 2 weeks prior to being seen in the ER. Pt does not remember an exact onset of symptoms but remembers waking up one morning and limping to the restroom. The pain seems to be a constant ache but does get better on lying flat in bed and is aggravated by bending, lifting, or walking. Pt denies radiating pain to other locations and has taken Motrin 200mg every 8 hours for 2 days but the pain is still occurring. Pt stated urine stream is steady and has been voiding 8-10 times a day. Pt states she has brown stools daily and has no difficulty using the restroom. Pt has gained 30 lbs. over the past year and is worried “this pain will cause me to gain more weight.” Past history does not reveal concerning health history outside of a family risk factor of diabetes as her mother has type II diabetes and takes insulin. Pt is an employed RN who has been treated with an appendectomy at 25 years old.

OBJECTIVE: A young woman who appears tired and overweight, presented sitting upright in a chair. Vital signs are as follows: blood pressure 116/70, apical heart rate 68/minute and regular, respiratory rate 17/minute, and temperature 98.6 F oral. Skin is cyanotic throughout and no significant trauma, bruise, or rash to the lower back or abdomen. All lung fields are resonant by percussion. Auscultation reveals clear breath sounds in all lung fields. Auscultation of the heart reveals S1S2, with no extra heart sounds or murmur. The abdomen is rounded, symmetric, soft, and non-tender. No hepatosplenomegaly or mass palpated. Back ROM is limited in the extension, rotation, and lateral bend. Pt can bend forward without limitation. Patient unable to perform straight leg raise to the right leg. The left leg is able to perform straight leg raise, all other hip movement is AROM, with no limitation. Decreased DTRs to popliteal and Achilles to the right leg. Bilateral triceps, bicep, and brachialis DTRs +2 and left leg popliteal and Achilles
DTRs +2.
Fill in the blanks and complete the questions below with REFERENCES FOR ALL SECTIONS:
1. ASSESSMENT [this is the 1) medical and 2) nursing diagnosis (NANDA sentence)].

1) ________________________________________________________________________________________
2) ________________________________________________________________________________________

2. What is the plan?

3. What is the diagnostic?
4. What is Therapeutic?

5. Education to the patient?

6. Are there other questions in subjective that should be asked?

7. Are there other objective findings you would like detailed for further care of the patient?

8. Is there anything you want to do before entering this room?

9. Is there anything you want to do before leaving this room—more than 1 answer here?

10. How did this assignment increase your knowledge related to these concerns?
PLEASE PROVIDE REFERENCES FOR ALL SECTIONS (1-10)

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