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CM 1 - Concept Map#3 Natalia Bortell Assessment Height 54...

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Concept Map #3 , Natalia Bortell Assessment: Height 5’4” Weight 120 lbs Lower back pain “7 out of 10” (reported to primary nurse) T: 98.8 BP: 122/69 P: 79 R: 20 A&Ox3 Extremity movement weak, limited No edema present q2hr neuro assessment Skin: warm and dry LBM: 3 days ago Frequency, urgency, no burning during micturition Vaginal discharge: “finger-tip size” thick white mucous, no red discharge #3. Ineffective Coping r/t change in health status, hospitalization and activity limitations aeb: - lack of understanding of bed rest limitations - verbalizing inability to cope - substance abuse - inability to meet role expectations as a mother #1. Impaired Physical Mobility R/T motor vehicle accident and lumbar spine fracture aeb: - MRI - inability to feed self - inability to perform active ROM exercises of arms, elbows, legs, ankles and knees Client: GB 31 y.o. female Admitted 10/12/11 Chief Medical Diagnosis: - Lumbar 1 fracture Medical history : - ADHD, GI bleeding, Depression, - Bipolar disorder, IV drug abuse, - Anemia, hyponatremia Social history : chronic IV drug abuser,
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