Read the following case study. Then, work through the steps

Read the following case study. Then, work through the steps of… Read the following case study.  Then, work through the steps of analyzing the case study data.  First identify abnormal data and strengths in subjective and objective findings, assemble cue clusters, draw interferences, make possible nursing diagnoses, identify defining characteristics, confirm or rule out the diagnoses, and document your conclusions.  Use the blank diagnostic analysis charts provided at the end of this book to guide your thinking.  Formulate nursing diagnoses that are specific to the client in the case study.  Identify collaborative problems, if any, for this client.  Finally, identify data, if any, which point toward a medical problem requiring a referral.Mrs. Marjorie C. is a 71-year-old woman, who has had diabetes mellitus for 15 years.  Her diabetes is controlled by diet and insulin.  A retired schoolteacher, she has lived alone for the past 7 years since her husband died of liver cancer.  Living in the upper level of a two-story apartment, she socializes with her neighbor and regularly attends church.  She has a grown son and a daughter, who both live out of state and call frequently but can visit only once a year.  Because of her poor eyesight, her neighbor, a retired RN, helps her draw up her insulin.  When visited by the home health care nurse, Mrs. C. states that she has had lower back and wrist pain for the past month.During the interview, Mrs. C. describes a sedentary lifestyle, spending much of her time watching TV, crocheting, or doing crossword puzzles.  She uses a magnifying glass for close work.  However, she has reduced her handwork because she has been having numbness and tingling in her right thumb and index finger.  The pain is relieved by rest, but she often has sharp pain in the right wrist during the night.  Mrs. C. has never smoked, does not drink alcohol, and has five cups of coffee a day.  She does little cooking.  Her diet primarily consists of TV dinners and canned soups, vegetables, and fruits, with very few dairy products.  She reports that constipation has become a more frequent problem over the past month.  She has maintained her weight of 63.5 kg (140 lb) for the past 10 years.  She can do most activities of daily living unassisted, but her neighbor does the grocery shopping.  She verbalizes embarrassment over the effects of the aging process and stooped posture, stating that she has noticed a decrease in her height over the past year.  Mrs. C. reports frequent low back aches with occasional sharp pains.  She tries to avoid bending to prevent pain, uses a heating pad, and takes Tylenol two or three times a day, which temporarily relieves the pain.  She experienced menopause at the age of 50 years and has never used estrogen replacement therapy.Physical examination reveals her to be 157.48 (5 ft 2 in) tall.  Two years ago, her height was 161.29 cm (5 ft 3 1/2 in).  Het gait is wide-based and slow.  Her temporomandibular joint (TMJ) has full range of motion (ROM) against resistance.  Mrs. C. has apparent kyphosis of the cervical spine.  Her paravertebrals are tender to palpation.  Lower back pain is aggravated by ROM, is limited to the lower lumbar area, and does not radiate down the leg.  The result of Lasègue test is negative.  No leg redness, nodules, tenderness, or swelling can be observed.  The ROM of the cervical spine and upper extremities are within normal range against gravity but decreased against resistance.  Lumbar flexion is 50 degrees; lateral bending is 25 degrees.  the legs are equal in length.  The shoulders, elbows, wrists, and fingers ate symmetric, without redness, heat, swelling, or nodules.  Some muscle atrophy is apparent in the upper extremities.  The results of Phalen’s test and Tinel’s test are positive.  The hips, knees, ankles, and toes are symmetric, without redness, swelling, heat, or nodules.  The lower extremities have full ROM against gravity, but decreased ROM against resistance.Health Science Science Nursing NCMA 111

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