med? (Can list related diagnosis, symptom, or need)8
Routine FindingsPatient Variations/AbnormalSkin – Patient’s skin is even and consistent with ethnicity. Skin is elastic and there are no signs of dehydration.Moderate non-pitting edema of the right fingers, fingers warm, capillary refill <2 seconds. Skin warm and dry. Head and neck – Patient’s head and scalp are normocephalic, there are no lesions or infestations.Facial expression is appropriate and facial featuresare symmetric. There are no tattoos or piercings. The lymph nodes are not palpable. Neck motion is smooth and controlled and has full ROMPERRLARespiratory – Lung expansion is symmetrical andthere are no masses or tenderness noted. Respirations are regular and even and chest expands symmetrically with each inspiration. Thereare no masses or tenderness noted. Lungs are clear, no adventitious sounds heard. Lungs clear.Cardiovascular- no mumurs, S1&S2 are heard. No jugular vein distention. pts chest is symmetric. Carotid pulse is palpable. Pedal pulses 2+. Radial pulse 2+ on left. Abdomen – Skin is even and pink throughout.Contour is flat. Abdomen is symmetric. Umbilical is midline. No pulsations present. Skin is intact. Bowels are active in all 4 quadrants. abdomen soft and non-tender with hypoactive BS in all four quadrants. Bowel continence? Last BM? Bowel Plan?Neurological – Pt A&O x4 to person, place, time, date, and situation. A&O to person, place, and situation. Musculoskeletal- Color is consistent with ethnicity. Contour of all joints are intact and equallybilateral. No crepitus, lesions, edema, masses, or deformitiesRadial joint not intact 9
Genitourinary - no lesions, rashes, wounds, tattoos, piercings, discharge. Urinary is consistent. Urinary continence? Toileting plan?Voided 200 mL clear amber urine. Nursing Diagnosis #1: Acute painRelated to (RT): Fracture of right radius As evident by (AEB): Pain 9/10 in right wrist and hand, dull and throbbing.Planning/Desired Outcome(s): D.H. will report her pain is controlled and tolerable by discharge. Implementation/Nursing intervention(s):Rationale Evaluation/Patient ResponseAssess if client is able to provides a self-report of pain intensity, and ifso, assess pain intensity level using valid and reliable self-report pain tool, such as the 0-10 numerical pain rating scale (Ackleyet al, Pg. 640).