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
Medications:
- 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
- QUESTION
- )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”)
