Past Medical History: Patient is alert, but very teary-eyed. She is very emotional as she talks abou. Question
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Past Medical History: Patient is alert, but very teary-eyed. She is very emotional as she talks about
her dog, saying “I really miss my Renny.” She has a history of severe arthritis and experienced
unrelieved pain in her right hip during the six months before her surgery. A total hip arthroplasty was
performed two days ago for her degenerative hip disease. The patient has a history of hypertension,
cataracts and hearing loss. The result of the INR drawn this morning was 2.5.
Situation:
Rosa de Luca is an 83-year-old female who had a total right hip replacement performed 48 hours
ago for her genenerative hip disease.
Background:
The patient has had a history of severe arthritis and unrelieved pain in her right hip for six months.
Assessment:
Vital Signs: HR 78, BP 183/112, RR 14, SpO2 93% on room air and temperature 38.0 ̊C
General Appearance: Teary-eyed
Cardiovascular: Normal sinus rhythm with systolic murmur
Respiratory: Breath sounds with coarse crackles bilaterally
GI: Normoactive bowel sounds
GU: Voiding without difficulty
Extremities: Pink and warm; pedal pulse to right foot is absent
Skin: Pink, warm and dry; skin turgor good
Neurological: Alert and oriented to person, place and time; pupils equal and reactive to light and
accommodation; no neurological deficits noted
IVs: Saline lock in right forearm
Labs: Morning INR/PT drawn; results pending
Fall Risk: High risk for falls
Pain: No complaints of pain
Social History: Patient is widowed and lives alone with her dog Renny, in a two-story house.
what are 3 nursing diagnoses? for each one put a short-term and a long-term goal.
include r/t and aeb
SCIENCE
HEALTH SCIENCE
NURSING
NURISNG PNS 202
Past Medical History: Patient is alert, but very teary-eyed. She is very emotional as she talks abou
