Case Study

Mrs. Angela Garcia is a 46-year-ol Hispanic woman who works as an x-ray

technician at a busy local hospital. She is being seen in the orthopedic clinic for
complaints of steadily worsening pain in her right knee. The pain began 4 months ago
when she fell and hyperextended the knee. Mrs. Garcia reports that the pain is more
intense with weight-bearing activities, including running, standing, and playing tennis.
Because of this, she has been limiting her physical activities. She also reports the
recent onset of painful muscle spasms in the right leg, both with activity and at rest.
The pain and muscle spasms are disrupting her sleep and making it difficult for her to
work. At home she has iterated the discomfort with acetaminophen and stretching
exercises but has experienced no relief.
On physical examination you notice a marked limp with walking, decreased
extension in the right knee, and a reluctance to allow her knee to be touched or
manipulated. The knee is slightly swollen and warm to the touch. During the x-ray
examination of the knee, she grimaces in pain when placed in a kneeling position.
Mrs. Garcia’s medical diagnosis is patellar tenonitis, and she is started on a
regimen of non-steroidal anti-inflammatory drug (NSAID).
As her nurse, you want to use the most accurate nursing diagnosis as a basis for
her nursing care. To begin the process of identifying a nursing diagnosis, you first
cluster the significant assessment data.

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