Patient Reliability

Name: E.L. Occupation: Registered Nurse

Source of History: Patient Reliability of Historian: Reliable

Age: 59 Date of birth: 1/15/1955

Race: Filipino Religion: Christian

Subjective Data:

Chief complaint: E.L. is in her usual state of good health until 5 days ago when she felt pain and swelling of right leg. Patient states that the swelling is more prominent after her work with pain mostly in her right groin.

History of Present Illness: 59 y/o Filipino female with Type II Diabetes diagnosed in 1998. She noticed slight swelling of her right lower extremity about one month ago after prolonged standing. Swelling is intermittent with slight discomfort which is relived by elevating her legs using 2 pillows.

Past Medical

2a - Risk for hypoglycemia related to eating less than body requirements.

2b - Risk for deficient fluid volume related to restricted intake.

Planning (Outcome/Goal):

1a - Patient will take short breaks from being on her feet throughout the work shift.

1b - Patient will wear compression stocking and report decrease of swelling during next work shift.

2a - Patient will eat a nutritious balanced diet.

2b - Patient will maintain good water intake.

Implementation:

1a - Patient will take frequent breaks during work shift and elevate leg while charting and report less leg pain after next work shift.

1b - Patient will be sized for compression stockings to use during work and when she will be on her feet for a long time.

2a - Patient will log her intake for 2 weeks and follow up with a nutritionist (Lifenurses, 2009)

2b - Patient will keep a log of her water intake to make sure she keeps well hydrated each day (Lifenurses, 2009).

Evaluations:

1a - Goal met. Patient states a decrease in pain after work shift.

1b - Goal not met. Patient did not wear compression stockings.

2a - Goal not met. Patient did not log her intake.

3a - Goal met. Patient reports drinking 6-8 glasses a