I'm new here and really need help for my assignments. I'm just join the nursing program and these are my first two assignment. I have no idea how to start it. May be somebody can help me. Thanks So much!!!!
case study # 1
1) Mrs Harriet Zoose, a patient admitted to a medical surgical nnit, has a medical diagnosis of acute exacerbation of ulcerative colitis. When obtain her health history, she tells you that she's currently experiencing painful abdominal cramps and has had very frequent bowel movements containing blood and pus for the past few days. She rates her discomfort level at 7 on a 10-point scale. She also states she has recently had trouble sleeping and feels extremely fatigued. She say the colitis has drastically decreased her sex drive, which is causing tension within her marriage.
On the physical exam, you assess:
VS:
BP 90/58
P 112
R 18
Temp 100.9
Hypoactive bowel sounds
Abdominal distension and tenderness
Pallor
An upper GI series performed the previous day found scarred and stenotic bowel segments, which are obstruction the intestinal flow.
The questions are:
Underline the data that is abnormal.
Identify as many NANDA bases as you can and list them out. At least 5.
List the diagnosis in order according to Maslow's Hierarchy of Needs and identify the stages.
Looking at your whole list, select the top 2 priorities nursing diagnosis.
List at least three nursing interventions with rationales (cite your references), for each of the two priority nursing diagnosis that you identified.
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Case Study #2
A 56 year old male is admitted to the medical surgical unit with chronic obstructive pulmonary disorder (COPD) and pneumonia. He has shortness of breath and audible wheeze. He's unable to answer all of the medical history questions, so his wife answers for him while he sits, leaning over the bedside table. She says he has been coughing up more sputum the past three days and that it's green in color.
His vital signs are:
-oral temperature 101.2° F
-pulse 115 bpm, irregular
-respirations 28 bpm, labored with accessory muscle use
-BP 142/68 mm/Hg.
During his physical exam the nurse notes 2+ edema of both feet.
On a separate sheet please type your responses to these questions and turn in with this page on the top. Please use care-map format for question #5. You may consult one another, and any text, however, your submitted work must be your own.
Underline data that is abnormal.
Identify as many NANDA bases as you can for Louise, and list them out. (At least 5)
List the diagnosis in order according to Maslow's Hierarchy of Needs and identify the stages.
Looking at your whole list, select the top 2 priority nursing diagnosis.
List at least three nursing interventions with rationales (cite your references), for each of the two priority nursing diagnosis, that you identified.
I just finished my other assignment that will due this Monday. Could you please have a look if I need to improve with any details. Because of your given info. For this one I think it is easier than the casestudy 1 & 2.
A 1000 thanks. :bowingpur
Instructions:
Underline abnormal signs and symptoms
Above abnormal data, Write O, if objective data and S, if subjective data.
Cluster data into related groups to identify and support each problem
Label actual and risk problems using NANDA nursing diagnoses( include related to, as evidenced by, or risk factors, as appropriate)
General Info. Provide by Client:
Mrs. Janice Watson. 46 years old, Female, Caucasian
Admission Date/ Time; March 15,1999; 9:00 a.m.
Admitting Medical Diagnosis: Intractable Vomiting, Dehydration
Arrived on Unit by : Wheelchair, from emergency department
Admitting Weight/ Vital signs: T 99 , P 76, R 20, BP 112/78; weight 145 pounds, height 5'3".
Clien's Perception of reason for admission: Client states she has had nausea and vomiting for 4 days.
Allegies: no know allergies ( NKA)
Medications: no presceiption medications; she took "Pepto-Bismol, but I can't keep it down"
Assessment data:
Oxygenation : Reports no difficulty breathing; respirations twenty per minute. States she is a nonsmoker. Breath sounds are clear to auscultation bilaterally; no cough. Apical pulse 76, strong and regular; radial pulses are equal in strength and quality, however, easily obliterated. Pedal pulses are regular and equal in strength. Denies any chest pain. Brisk capillary refill of fingernail beds. No pedal, ankle, or leg edema noted.
Temp: 99.0 F, denies having any fever over last few days
Nutritional / Fluid: She has an IV for hydration and electrolyte replacement in her right forearm. 5'3" height, 145 pounds; weight has been relatively stable, until now. Reports weight loss of about 5 pounds since she became ill. States, " I haven't been able to eat for 4 days." Reports she normally eats two regular means each day and has not been dieting. She complains of generalized abdominal cramping and is nauseated now. "I was trying to vomit in the emergency department, but there's just nothing in my stomach." Her skin turgor is inelastic, oral mucous membranes pink, but sticky.
GI/ Elimination : Reports last bowel movement was two days ago; no diarrhea. Normal pattern is one bowel movement everyday; states she urinated once yesterday. Abdomen is slightly distended and tender to palpation. Bowel sounds are present, but hypoactive.
Rest/ Sleep: She state she has no difficulty sleeping at home, before she became ill. Denies use of sleeping aids or medications.
Pain Avoidance: Generalized abdominal cramping, described as sharp, intermittent, and rated as "six" on scale of one to ten. Nurse observes client holding her abdomen and stomach region.
Sexuality / Reproductive: Menstrual periods are usually regular, every twenty-eight days. Clients reports she had a tubal ligation after the birth of her second child about twenty years ago. Denies any concerns with sexual aspect of her life.
Activity: States she is active and has no problem. Client reports no aerobic activity, walks occasionally. Works as legal secretary for a well-known attorney. Enjoys going to the theatre with her husband and reading in her spare time.
Additional Data: The client is alrert and oriented; responds appropriately to questions. Her eyes have a sunken appearance. Denies visual or auditory problems. The clients' skin is intact, warm, and dry. Her hands tremble and she states, "Just leave me alone. I don't want to move."
Abnormal Subjective Data:
Nausea and vomiting for 4 days
Complains of generalized abdominal cramping and is nauseated now.
Reports last bowel movement was 2 days ago, no diarrhea.
Urines once yesterday.
Generalized abdominal cramping, described as sharp, intermittent, and 6 on scale of one to ten.
States to just leave her alone. She doesn't want to move.
Abnormal Objective Date:
Redial pulses is easily obliterated.
Her skin turgor is inelastic
Oral mucous membrane is sticky
Abdomen is slightly distended and tender to palpation.
Hypoactive bowel sounds
Client holding her abdomen and stomach region.
Her hands tremble.
Cluster data into groups of related data to determine problem.
Cramping/ Pain
Complains of generalized abdominal cramping and is nauseated now.
Generalized abdominal cramping, described as sharp, intermittent, and 6 on scale of one to ten.
States to just leave her alone. She doesn't want to move.
Abdomen is slightly distended and tender to palpation.
Hypoactive bowel sounds
Client holding her abdomen and stomach region.
Her hands tremble.
Fluid/ Nutrition
Nausea and vomiting for 4 days
Reports last bowel movement was 2 days ago, no diarrhea.
Urines once yesterday.
Her skin turgor is inelastic
Dry skin and oral mucous membrane is sticky
Determine NANDA nursing diagnosis.
Constipation R/T inadequate fluid intake AEB reports last bowel movement was two days ago.
Fluid Volume Deficit R/T vomiting/ nausea AEB dry skin and sticky oral mucous membrane, Urines once yesterday.
Acute Pain R/T impair comfort AEB abdominal cramping, sharp, intermittent and rated as 6 on a 10-point scale.
Specializes in med/surg, telemetry, IV therapy, mgmt.
my corrections or additions are in red or blue.
abnormal subjective data:
nausea and vomiting for 4 days
complains of generalized abdominal cramping and is nauseated now.
reports last bowel movement was 2 days ago, no diarrhea.
urines once yesterday.
generalized abdominal cramping, described as sharp, intermittent, and 6 on scale of one to ten.
states to just leave her alone. she doesn't want to move.
reports weight loss of about 5 pounds since she became ill.
" i haven't been able to eat for 4 days."
abnormal objective data:
redial pulses is easily obliterated.
her skin turgor is inelastic
oral mucous membrane is sticky
abdomen is slightly distended and tender to palpation.
hypoactive bowel sounds
client holding her abdomen and stomach region.
her hands tremble.
eyes have a sunken appearance.
cluster data into groups of related data to determine problem.
cramping/ pain
complains of generalized abdominal cramping and is nauseated now.
generalized abdominal cramping, described as sharp, intermittent, and 6 on scale of one to ten.
states to just leave her alone. she doesn't want to move.
abdomen is slightly distended and tender to palpation.
hypoactive bowel sounds
client holding her abdomen and stomach region.
her hands tremble.
fluid/ nutrition
nausea and vomiting for 4 days
reports last bowel movement was 2 days ago, no diarrhea.
urines once yesterday.
her skin turgor is inelastic
dry skin and oral mucous membrane is sticky
determine nanda nursing diagnosis.
constipation
r/t dehrdration, inadequate fluid intake aeb reports last bowel movement was two days ago.
fluid volume deficit
r/t fluid volumn loss aeb vomiting x 4 days, inelastic skin torgor, dry skin and sticky oral mucous membrane, urinated only once yesterday.
acute pain
r/t impair comfort aeb abdominal cramping, sharp, intermittent and rated as 6 on a 10-point scale. - wouldn't use
disturbed sleep pattern
r/t pain aeb abdominal cramping. - she said she didn't have any trouble sleeping
nausea
r/t sick to the stomach aeb nausea and vomiting for 4 days and weight loss 5 pounds and haven't been able to eat for 4 days. - wouldn't use since the patient is already reporting vomiting
cloudybay
10 Posts
Hi Daytonite,
I just finished my other assignment that will due this Monday. Could you please have a look if I need to improve with any details. Because of your given info. For this one I think it is easier than the casestudy 1 & 2.
A 1000 thanks. :bowingpur
Instructions:
General Info. Provide by Client:
Mrs. Janice Watson. 46 years old, Female, Caucasian
Admission Date/ Time; March 15,1999; 9:00 a.m.
Admitting Medical Diagnosis: Intractable Vomiting, Dehydration
Arrived on Unit by : Wheelchair, from emergency department
Admitting Weight/ Vital signs: T 99 , P 76, R 20, BP 112/78; weight 145 pounds, height 5'3".
Clien's Perception of reason for admission: Client states she has had nausea and vomiting for 4 days.
Allegies: no know allergies ( NKA)
Medications: no presceiption medications; she took "Pepto-Bismol, but I can't keep it down"
Assessment data:
Oxygenation : Reports no difficulty breathing; respirations twenty per minute. States she is a nonsmoker. Breath sounds are clear to auscultation bilaterally; no cough. Apical pulse 76, strong and regular; radial pulses are equal in strength and quality, however, easily obliterated. Pedal pulses are regular and equal in strength. Denies any chest pain. Brisk capillary refill of fingernail beds. No pedal, ankle, or leg edema noted.
Temp: 99.0 F, denies having any fever over last few days
Nutritional / Fluid: She has an IV for hydration and electrolyte replacement in her right forearm. 5'3" height, 145 pounds; weight has been relatively stable, until now. Reports weight loss of about 5 pounds since she became ill. States, " I haven't been able to eat for 4 days." Reports she normally eats two regular means each day and has not been dieting. She complains of generalized abdominal cramping and is nauseated now. "I was trying to vomit in the emergency department, but there's just nothing in my stomach." Her skin turgor is inelastic, oral mucous membranes pink, but sticky.
GI/ Elimination : Reports last bowel movement was two days ago; no diarrhea. Normal pattern is one bowel movement everyday; states she urinated once yesterday. Abdomen is slightly distended and tender to palpation. Bowel sounds are present, but hypoactive.
Rest/ Sleep: She state she has no difficulty sleeping at home, before she became ill. Denies use of sleeping aids or medications.
Pain Avoidance: Generalized abdominal cramping, described as sharp, intermittent, and rated as "six" on scale of one to ten. Nurse observes client holding her abdomen and stomach region.
Sexuality / Reproductive: Menstrual periods are usually regular, every twenty-eight days. Clients reports she had a tubal ligation after the birth of her second child about twenty years ago. Denies any concerns with sexual aspect of her life.
Activity: States she is active and has no problem. Client reports no aerobic activity, walks occasionally. Works as legal secretary for a well-known attorney. Enjoys going to the theatre with her husband and reading in her spare time.
Additional Data: The client is alrert and oriented; responds appropriately to questions. Her eyes have a sunken appearance. Denies visual or auditory problems. The clients' skin is intact, warm, and dry. Her hands tremble and she states, "Just leave me alone. I don't want to move."
Abnormal Subjective Data:
Abnormal Objective Date:
Cluster data into groups of related data to determine problem.
Cramping/ Pain
Fluid/ Nutrition
Determine NANDA nursing diagnosis.
Please advice. thanks