Med/Surg - Case Study Help!

  1. Could I please get your thoughts on this case study?
    I'm having problems with figuring out what more (possibly) could be going on given the information.
    Thank you!

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    Mr. H. is a 64 yo male with H/O COPD, HTN, Type II DM. He just arrived this am from the EC with the diagnosis of uncontrolled HTN, (Admitting BP was 220/110), and Chest Pain. The symptoms that brought him into the EC were severe morning H/A with occasional vomiting X 3 days, SOB and C.P. When you examine him you notice a large bruise on his right elbow and hip. He relays a H/O a fall recently. He complains of dysphagia which he attributes to a sore throat from vomiting. He ia slightly disorientated and drowsy, but received a dose of Zofran for vomiting before he was brought up to your unit.His HA has returned but he feels he can not take anything po because of his earlier vomiting.

    Labs: Na: 145, K: 3.7, Cl:110, C02: 28, BUN: 22, CRT: 1.5, BS 210
    Hgb 12.7, WBC: 10.3, PLTS: 110. CK enymes neg
    Chest X-Ray: No effusions, pnemonia but emysematous changes noted.
    Current BP: 156/98 HR:78 reg., RR: 24 on 4L O2

    What could be happening to Mr. H.? Hint: Is all his symptoms related to HTN?

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    My impressions:

    The symptoms that he's exhibiting seems related to his HTN and COPD.

    His uncontrolled HTN is probably what is causing his severe HA which in turn is causing his N/V.

    The SOB and RR: 24 is due to the COPD w/ emphysematous changes.

    His bruising is from the fall and was also contributed to by a PLT: 110.
    Besides medication, I don't know what else could be causing his low platelets. He doesn't have a history of a blood disorder.
    I would check his medications to see if something could be causing it.

    His Cl and Cre are elevated. Possible renal insufficiency related to HTN and DM? But his BUN is normal.

    I think CBC and ABG should be drawn to better assess.
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  2. 2 Comments

  3. by   flaerman
    Also would want to check his PT/PTT and D-Dimer(if elvated could have PE which could explain SOB and CP)-then would need CT chest /angio study, and did he have a CT of head/brain, the BP (150's/90's) although sl elevated would not always cause a H/A(the initial presenting BP would be more a cause for H/A)-need to R/O CVA especially with H/A, disoreientation and drowsiness(and H/O fall as well). flaerman
    Last edit by flaerman on Oct 29, '07
  4. by   Daytonite
    first of all, stop trying to think like a doctor and diagnosing in terms of medical diagnoses. we are nurses, not doctors. let me get you started on the right road here. you are being asked to problem solve here--that's what we nurses do. we have a way to do that. it's called the nursing process. it has these steps:
    1. assessment (collect data from medical record and by doing a physical assessment of the patient)
    2. nursing diagnosis (make a list of the abnormal assessment data, match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnosis to use)
    3. planning (write measurable goals/outcomes and nursing interventions)
    4. implementation (initiate the care plan)
    5. evaluation (determine if goals/outcomes have been met)
    now, for step #1, the assessment, you have already been given a slew of data, most of it abnormal data. these are the patient's signs and symptoms and they form the foundation of the problems he is having. problems are yet to be determined. his abnormal data include the following:
    • severe morning headache
    • occasional vomiting x 3 days
    • dysphagia which he attributes to a sore throat from the vomiting
    • shortness of breath (sob) and is on 4l of oxygen
    • chest pain (c.p)
    • large bruise on his right elbow and hip due to a recent fall
    • slightly disorientated and drowsy
    • admission bp 220/110, currently 156/98
    • slightly elevated bun of 22 (normal is 10-20) - the bun is elevated in hypovolemia, shock , burns, dehydration, chf, mi, gi bleeding, excessive protein ingestion, starvation, sepsis, renal disease, renal failure, nephrotoxic drugs, ureteral obstruction and bladder outlet obstruction.
    • creatinine (crt?) of 1.5 (normal is 0.6 - 1.2 for males) - the creatinine is elevated in glomerulonephritis, pyelonephritis, acute tubular necrosis, urinary tract obstruction, shock, dehydration, chf, diabetic nephropathy, nephritis, rhabdomyolysis, acromegaly and gigantism
    • blood sugar of 210 [his diabetes]
    • hemoglobin of 12.7 (normal male is 14-18) - hemoglobin is decreased in anemia, severe hemorrhage, hemolysis, cancer, nutritional deficiencies, lymphoma, sle, and kidney disease [may be related to an occult underlying renal complication of the diabetes]
    • white blood cell count 10.3 (normal adult is 5-10) - this is only slightly elevated - wbc is elevated in infection, trauma, stress, tissue necrosis, and inflammation [any chronic inflammation here could be related to his copd]
    • platelets 110 (normal is 150-400) - platelets are decreased in hemorrhage, leukemia, dic, sle, pernicious anemia, hemolytic anemia, cancer chemotherapy and infection [again, may be related to the chronic copd or an occult complication of the diabetes]
    • cxr shows emphysematous changes [this is his copd]
    • symptoms of copd include scant sputum production with emphysema, excessive sputum production with chronic bronchitis, exertional dyspnea, chronic productive cough with chronic bronchitis, hypoxia with emphysema and cyanosis with chronic bronchitis, tachypnea, prolonged expiration, hyperresonant chest, diminished breath sounds, coarse rhonchi and wheezes in bronchitis, s3 gallop, edema,
    • symptoms of htn include b/p over 140/90, elevated blood pressure, occipital headache upon awakening, dizziness, fatigue and/or confusion, palpitations, chest pain, dyspnea, epistaxis, hematuria, blurred vision, bounding pulse, s4 heart sound, late stages (peripheral edema, hemorrhages, exudates, papilledema of the eye due to hypertensive retinopathy, possible formation of an abdominal aneurysm, bruits over the abdominal aorta, femoral arteries and/or carotid arteries)
    • symptoms of uncontrolled diabetes include polyuria, polydipsia, nausea, anorexia, polyphagia, headaches, fatigue, lethargy, reduced energy levels, muscle cramps, irritability, vision changes, numbness and tingling in extremities, abdominal discomfort
    this is all the preliminary work you should have done as part of step #1 of the nursing process for this case study. you have a whole bunch of symptoms to sort through and group into nursing diagnoses which is step #2 of the nursing process. it is true that the side effects of zofran are drowsiness, but not the disorientation. that's probably related to the diabetes and dehydration.

    if you look at the symptoms of his medical diagnoses of copd, htn and the uncontrolled diabetes you will see that his admitting symptoms of the morning headache, the vomiting, the shortness of breath and chest pain are all symptoms of these medical diagnoses. and, that is what is going on with mr. h. in addition to all this he probably has some dehydration (nursing diagnosis: deficient fluid volume) as a result of his 3 days of vomiting which will account for some of his abnormal lab results. the doctors are treating his copd with supplemental oxygen. they are also treating his vomiting with zofran.

    you need to determine his nursing diagnoses from the above abnormal data (signs and symptoms) and then goals and nursing interventions for the signs and symptoms in order to complete this case study--if that is what you are required to do.

    any time you have a problem to solve, you always use the nursing process to do it. always. it will help direct your thinking.

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