Mr. J is a 35 year old male who arrives at the emergency department ( ED ) with a complaint of unbearable intermittent pain that started one day ago , while at work . He felt nauseated and was diaphoretic later that day . He was unable to take fluids because the nausea would not subside . The following day he observed that his urine was scant and the color was pink-red . He went to work because the pain had decreased much . While at work , he felt a pain radiated from his left side of the abdomen to the centre and it was severe for a few minutes . He informed his brother who work nearby , and transported him to ED at once . Mr. J denies previous episodes of this type of pain and has no past or current medication history . His vital signs are within normal limits except for a temperature of 38.3'c . Laboratory evaluation : Ct scan shows calcium oxalate crystal in the left kidney calyx urine dipstick shows positive for hematuria urinalysis reveals red blood cells the urine has no odor or turbidity a) classify the data presented in the clinical summary under primary and secondary data . b) identify two actual nursing diagnoses and two potential nursing diagnoses for Mr. J by using PES / PE format .
Mr. J is a 35 year old male who arrives at the emergency department ( ED ) with a complaint of unbearable intermittent pain that started one day ago , while at work . He felt nauseated and was diaphoretic later that day . He was unable to take fluids because the nausea would not subside . The following day he observed that his urine was scant and the color was pink-red . He went to work because the pain had decreased much . While at work , he felt a pain radiated from his left side of the abdomen to the centre and it was severe for a few minutes . He informed his brother who work nearby , and transported him to ED at once . Mr. J denies previous episodes of this type of pain and has no past or current medication history . His vital signs are within normal limits except for a temperature of 38.3'c .
Laboratory evaluation :
Ct scan shows calcium oxalate crystal in the left kidney calyx
urine dipstick shows positive for hematuria
urinalysis reveals red blood cells
the urine has no odor or turbidity
a) classify the data presented in the clinical summary under primary and secondary data .
b) identify two actual nursing diagnoses and two potential nursing diagnoses for Mr. J by using PES / PE format .
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