The purpose of this project is to become familiarized with factual case studies, become content with collecting data, formalizing nursing diagnosis, and interventions. This project will help us learn how to essentially connect our health assessment and pathophysiology education. After completing this project we will be able to devise nursing diagnosis and interventions confidently and become further knowledgeable about the necessary subject matters. Nursing Physical Assessment The patient presented to our group is a 68 year old African American woman who has a history of hypertension, apparent asthma, hyperlipidemia, and osteoarthritis. She has had a hysterectomy and a family history of noncontributory. Home medications consist of Spironalactone 50mg p.o. daily. Patient lives at home with her family; she hasn’t had any form of tobacco in over 30 years and does not consume any form of alcohol. Client was in her typical state of health up until last Tuesday; which is when she began to have lower quadrant abdominal pain. Subjective data collected was “there was more pain on …show more content…
Hypovolemia is also known as deficient fluid volume in the blood. This disorder is fluid and electrolyte imbalance which is evidenced by our client’s blood results. With hypovolemia, your cells are fluid and electrolyte deprived and can either cause the lysing or crenation of your cells. One of the causes of hypovolemia is frequent loss of fluid, which coincides with our client’s diagnosis of urge incontinence. One of the electrolyte imbalances that our patient had was hypokalemia. Hypokalemia is a potassium level that is lower than the normal range or 3.5. Mild symptoms of hypokalemia include, abnormal heart rhythms (dysrhythmias), especially in people with heart disease, constipation feeling of skipped heart beats or palpitations, fatigue muscle damage, muscle weakness or spasms, tingling or numbness (Saunders,
HPI: MR is a 70 y.o. male patient who presents to ER with constant, dull and RUQ abdominal pain onset yesterday that irradiate to the back of right shoulder. Client also c/o nauseas, vomiting and black stool x2 this morning. He reports that currently resides in an ALF; they called the ambulance after his second episodes of black stool. Pt reports he drank Pepto-Bismol yesterday evening without relief. Pt states that he never experienced similar symptoms in the past. Denies any CP, emesis, hematochezia or any other associated symptoms at this time. Client was found with past history gallbladder problems years ago.
The SMART goal for the patient’s diagnosis of diarrhea is that the patient will defecate formed, soft stool every 1 to 3 days and will express relief of cramping with little or no diarrhea. The intervention to meet this smart goal is the administration of fidaxomicin, a narrow spectrum antibiotic, to treat the infection of Clostridium difficile (Sears, 2013). Another nursing intervention for the treatment of diarrhea is assessing the patient for sodium and potassium loss, as well as explaining the prevention methods to avoid the spread of excessive diarrhea (Mitchell, 2014). The nurse must also provide proper skin integrity care to the peritoneal are and make the environment safe and easy for access to the bathroom. The SMART goal for the patient’s diagnosis of acute pain is that the patient will state relief of pain in abdominal area after treatment with opioids in a 24hr period. The nursing intervention for acute pain is the administration of opioids as well as positioning to keep patient in as much comfort as possible and take pressure off of the abdominal area. The nurse must also assess the patient’s vital signs and pain level
2) Mrs. Wong goes to the emergency room with the following symptoms: severe pain in the umbilical region, loss of appetite, nausea, and vomiting. While she was waiting to see a doctor, the pain moved to the lower right abdominal quadrant. What is the diagnosis and treatment?
J.P., a 58 year old female, presents to the Emergency Room on March 18th. She has a past medical history of cervical cancer, atheroembolism of the left lower extremity, fistula of the vagina, peripheral vascular disease, neuropathy, glaucoma, GERD, depression, hypertension, chronic kidney disease, and sickle cell anemia. She complains of right lower extremity pain accompanied by fatigue, a decreased appetite, increased work of breathing, burning urination, and decreased urine output for three days. Upon admission, a complete physical assessment was performed along with a blood and metabolic panel. The assessment revealed many positive and negative findings.
Wilson, Susan. (2009). Health Assessment for Nursing Practice (5th ed., pp. 520-521). St. Louis, MO: Elsevier Mosby.
The patient is a 56-year-old gentleman who presented to the ED with a complaint of constipation for 5 days prior to presentation patient reports child the being bags of sunflower seeds 6 days prior to presentation and since that time he has not had a bowel movement. He reports some associated left lower quadrant pain 2/10, sharp and constant. He also reports associated increased urinary frequency and straining to urinate. He has no significant past medical history. He has tried some stool softeners etc. at home with no results. Clinical review of his records indicates he does have a mild elevation in his white count with a left shift. His SMA-18 reveals some hypokalemia. Urinalysis reveals a small amount of blood. A CT the abdomen
Taylor, C. R., Lillis, C., LeMone, P., & Lynn, P., (2011). Fundamentals of nursing: The art and science of nursing care (7th ed.). Philadelphia, PA: Lippincott Williams & Wilkins
constant pain in upper abdomen, and people can be disabling due to severe pain, weight loss
Spark Ralph, S. & Taylor, C. M. (2011). Nursing diagnosis reference manual (8th ed.). Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins.
ANA describes “The Scope of Nursing Practice (as) the “who,” “what,” “where,” “when,” “why,” and “how’ (8).’ In other words, it is the responsibility of the nurse to know who their patient is, what the patient’s diagnosis and treatment are, where it is they will be delivering treatment, the rationale behind their actions, and how they will deliver the care. By following the scope of practice, nurses reduce avoidable errors and are aware of the liability their actions entail. The ANA also puts forth a nursing process to guide nurses in treatment. The constantly evolving process is currently assessment, diagnosis, identification of outcomes, planning, implementation, and evaluation (ANA 9). Though this method has dramatically improved nursing care, it may be necessary to repeat steps to adapt to a patient’s changing needs and pathologies. By following guidelines set by the ANA, nurses are able to better connect with their patients and instill the image of professionalism to the public while also optimizing safety
Price, N. and Currie, I. (2010) ‘Urinary Incontinence in women: diagnosis and management’, Practitioner, 254(1727).
St. Louis, MO: Elsevier Ackley, B.J., Ladwig, G.B., & Flynn Makic, M. (2017). Nursing diagnosis handbook (11th ed.). St. Louis, MO: Elsevier University.
Potter, P. A., & Perry, A. G. (2005). Fundamentals of nursing (6th ed.). St. Louis, MO: Mosby,
Taylor, C., Lillis, C., LeMone, P., Lynn, P. (2011). Fundamentals of nursing: The art and science of nursing care (7th ed.). Philadelphia: Wolters Kluwer Health/Lippincott Williams &
Gordon, M. (2007). Manual of nursing diagnosis: including all diagnostic categories approved by the North American Nursing Diagnosis Association (11th ed.). Sudbury, Massachusetts: Jones and Bartlett.