Pain (L. leg joint)
A Coggle Diagram about OBJECTIVE DATA (*102 y.o. Female
*Ht. 67 in.
*Wt. 167.4 lb.
*Pleasant attitude, good mood
*No distress noted
*CN 3 impaired
*bowel sounds x 4Q
*Strong grip strength, leg strength, arm strength
*Decreased ROM of L. knee
*Pain when L. knee is flexed
Pt. Seen crying after support staff transferred her to her bed."
when CNAs helped, pt. was withdrawn, VITAL SIGNS:
Temp. 98 F
O2 sat 96%, Allergies: Penicillins, Code: DNR and I/O: input- 100% of breakfast, 100% of lunch, 480ml
Output- 2 briefs (unmeasured amount), no stool), Neuman's Systems Model, SUBJECTIVE DATA (*Pain 1/10
*Pt. states "they don't listen to me here. I have to scream when I'm in pain so they will stop."
*Pt. States "God saves those who are good and do good things."
*Pt. States "My son died in the military."
*Pt. states "I don't see very well, or hear very well."
*My son and daughter in law often visit with my grandkids."
Pt. states "I wish I was dead," while crying after transferred to her bed.
Pt. stated "we are all here because there was nowhere else to put us."
Pt. stated "I wish I would just die."), NANDA Nursing Diagnosis I, DX:
S/P fall (11/21/16) alert with confusion,
Pacemaker, L. leg joint pain, cervicalgia, joint pain shoulder, SOB, cough, Reps. System disease NOS, cardoimegaly and NANDA II (Hopelessness r/t deteriorating physiological condition, e/b pt. statement of "wanting to die," and "we are all here because there was nowhere else to put us," and lack of involvement in care.)