Question

PV PE You are the clinic triage nurse and are assessing a patient that is on today as a nurse only visit. Upon entering the room, your patient tells you the following. "I am 65 now but I first noticed my problem when I was 64. I was on vacation in Rome, Italy. Maybe the 9 hour flight contributed to bringing my peripheral vascular disease (PVD) to the surface. After walking about a block or two, both my legs hurt so bad I had to stop and rest. After a miserable vacation, I came home. I was seeing doctors for back pain. After useless injections, a physician's assistant suggested a hip X-ray. I am here today to get the help I need." Your assessment revels the following. Edema in the lower extremities at 3+. Poor toenail care. Warm and dry skin on shins of both legs. Legs are not normal skin color for the patients ethnicity. Faint pedal pulses. B/P 168/82, HR 81, 02 95%, Wt in chart from last year

Subjective, objective and abnormal documentation. Physical assessment

Answer 1

Subjective data

• Swelling
• back pain
• Fatigue
• Decreased urine output
• Increased weight

Objective data

• edema
• Weak pedal pulse
• Weight gain
• Dehydration
• Poor nutrition
• dry skin

Documentation

patient has leg edema, weakened pulse, oliguria, dehydrated and gained weight.

Physical assessment

• dry Skin
• Increased blood pressure
• Peripheral edema
• Pale skin color
• groin pain
• heart murmur
• decreased urine output
• dry eyes