Help on Diagnosis Care Plan

NurseDD5 · Sep 20, 2011

Case Study

Carla Dillon is a 70 year old frail Caucasian female with a 5 day history of intractable vomiting, fever ranging between 101-102 F, and non-specific back pain. Over the past 2 days, she has had 5 liquid stools per day and can not tolerate a regular diet.

Chief Complaint: "I ache all over and can't seem to keep any food down. I can't afford to lose any weight."

Abnormal Lab Values report:

CBC with Diff

WBC: 22,000 (H) RBC: 6.1 (H)

Lymphocytes: 67 (H) HCT: 55% (H)

Hgb: 18 (H)

Chemistry

Na: 133 (L) BUN: 22 (H)

CO2: 12 (L) Creat: 27 (H)

Glucose: 52 (L)

Urinalysis

Color: dark amber Culture: pending

Specific gravity: 1.035 (H) pH: 8.5 (H)

Cultures

Stool: pending

Blood: pending

Admitting Orders:

Admitting Dx: Dehydration 5%, Fever

Diet: Clear liquid, advance as tolerated

Vital Signs every 4 hours

Strict I&O's

IVF: D5LR to run at 100 mL/hr

Medications:

Lopressor: 100 mg PO once a day MVI: 1 tab PO once a day

Tylenol PRN for temperature over 101

Admitting Assessment:

General Survey: Frail 5 ft tall, 100 lb elderly female. Presented to ER and arrive to floor alone with an emesis basin. Face pale in color. Currently, shivering uncontrollably.

Vital Signs: Temp: 102 F (oral), Pulse: 128 (bounding, regular), Resp: 30, BP: 98/52, O2 sat: 96% on RA, Pain Scale 2/10

Skin: Face pale. Warm, flushed with decreased turgor.

Neuro: EOM's sluggish

Thorax: Apical pulse 120 strong, regular. Respirations 30 equal chest rises, labored with slight use of accessory muscles

Abd: tender to touch with hyperactive bowel sounds. Last bowel movement in ER; loose to watery brown with foul odor

GU: No discharge or odor noted. Last void in ED of 100 ml of urine

Extremities: Ambulates with walker.

Psychosocial: Retired school teacher. Husband died last year. Son lives out of state. Lives alone in retired community, but has many friends and is active within her community.