Mrs. Regina Smith, a 34-year-old female, comes to the health care provider’s office with concerns about muscle weakness and lower back pain. She saw a specialist who gave her a steroid injection but it “didn’t help”.

Past Medical History: Asthma, Type II Diabetes, Polycystic Ovarian Syndrome

Past Surgical History: Denies

Family History: Mother is diabetic and her father has hypertension

Social History: Denies smoking, alcohol or drug use


  • Mometasone 220mcg 1 inhalation every 24 hours

Subjective Data:

  • Has multiple bruises for no apparent reason
  • Waxing her upper lip and chin frequently to remove excess hair
  • No appetite
  • Unexplained weight gain especially around her midsection
  • Irregular menstrual cycles
  • Feeling depressed

Objective Data:

  • Blood pressure (BP) 150/82
  • Pulse 90 beats/minute
  • Respiratory rate 22 breaths/minute
  • Temperature 99.6° F
  • Pain 8/10 non radiating, aching lower back pain
  • O2 saturation: 100% on room air

Physical Exam:

  • HEENT: Moon face, acne on forehead, hirsutism, extra fat around neck
  • Neuro: Alert & oriented X 4
  • Cardiovascular: S1, S2 rate regular, 2+ pitting edema of lower extremities
  • Respiratory: Clear to auscultation bilaterally
  • GI: Truncal obesity ,+bowel sounds X 4 quadrants
  • GU: Voiding freely
  • Skin: Thin skin, multiple bruises on various areas of her body
  • Extremities: Thin extremities
  2. )Identify 5 nursing diagnoses that would be appropriate in developing a plan of 
    care for R.S (must include “related to” and “as evidenced by”)