Concept Map #3, Natalia BortellAssessment:Height 5’4” Weight 120 lbs Lower back pain “7 out of 10” (reported to primary nurse)T: 98.8BP: 122/69P: 79R: 20A&Ox3Extremity movement weak, limitedNo edema present q2hr neuro assessmentSkin: warm and dryLBM: 3 days agoFrequency, urgency, no burning during micturitionVaginal 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 andlumbar spine fracture aeb:-MRI-inability to feed self-inability to perform active ROM exercises ofarms, elbows, legs, ankles and knees Client:GB 31 y.o. female Admitted 10/12/11Chief Medical Diagnosis: - Lumbar 1 fractureMedical history:-ADHD, GI bleeding, Depression,-Bipolar disorder, IV drug abuse, -Anemia, hyponatremiaSocial history: chronic IV drug abuser,
This is the end of the preview.
access the rest of the document.
Hemoglobin, Iron deficiency anemia, Morphine, Spinal disc herniation, Lumbar vertebrae