Scl 101 Case Study Essay

SCL 101 FALL 2016
Case Study Assignment

Subjective Data 1. Ms. Smith says “that she has been experiencing painful abdominal cramps and has had frequent loose bowel movements about 3 per day.." 2. She notices she has about 5-6 watery bowel movements mostly bloody with white stuff like mucus or pus 3. Patient stated discomfort and pain level is 7 out of 10 on the numeric pain scale 4. Mary Smith stated “She has trouble sleeping and feels extremely tired and fatigued.” 5. Patient says “The constant use of the bathroom for bowel movement has drastically decreased her sex drive, altered her social life, and is causing tension in her marriage

Objective Data 1. Vitals signs: BP 90/60, HR(heart rate) 90-100, RR(respiratory rate) 22, Temp: 100.2 F, Oxygen Saturation: 98% 2.

slowed capillary refill.

Carpenito, L. J. (2013). Handbook of Nursing Diagnosis (14th ed.). Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins Health.

Acute Pain • Interdependent: As prescribed by Doctor, administer Morphine Sulfate 4mg IM(intramuscular) prn for pain greater than 6 out of 10. After administration, return in 30 minutes to assess effectiveness.
Rationale: Pain can aggravate other symptoms and cause extreme discomfort.

Carpenito, L. J. (2013). Handbook of Nursing Diagnosis (14th ed.). Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins Health.

• Independent: Provide pain-relief through comfort by repositioning and massages.
Rationale: Promote relaxation, reduce abdominal tension, and divert attention away from pain.

Carpenito, L. J. (2013). Handbook of Nursing Diagnosis (14th ed.). Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins