In need of help ... STRESSED OUT!!!

[lovelylia]

hi guys, i was wondering if anybody couldl help me out with an assignment i have been presnted with.. i have no idea where to begin and how to get ot started you see i have all the information but dont know how to get it started if that makes sense... fron the case scenario i am to establish what nursing intervention she needs and what could be causing her to have those symptoms any feedback would be much appreciated thank u so much.

catherine wilkes a 22 year old unemployed single mother was admitted 2 days ago through emergency department for collapse for investigation. on arrival at triage it was noted that catherine had her two-year old child at her side and both appeared unkempt. catherine's observations were taken at triage and her blood pressure was report as 75 mmhg / not detectable. her speech was incomprehensible, but all limbs were equal in power and pupils were equal and reacting to light. she was promptly transferred to the cubicle area.

whilst in emergency department she underwent a physical examination and blood work up. her speech at this time had improved but was slurred. she was reluctant to discuss her family history.

health status: non smoker

moderate alcohol intake

ulcerative colitis for 6 years

ileoanal anastomosis 14 months ago

observations: temperature 360c

bp now 90/60

respirations 22 breaths per minute

pulse 130 beats per minute

o2 saturation 100% on room air

physical assessment: weight 45kg

height 160 cm

bruises to lower limbs

chest clear

abdomen soft, non tender

blood results:

bgl 7.2 mmol sodium 124 mmol/l

hb 116 g/l potassium 5.2 mmol/l

hct 0.38l/l chloride 89 mmol/l

rcc 4.8 x 1012/l bicarbonate 23 mmol/l

mcv 78 fl anion gap 17

wcc 16 x 109/l urea 10.3 mmoml/l

esr 34 mm/hr creatinine 0.12 mmol/l

crp 31 mg/l

catherine reported to the medical officer that she had felt nauseous and dizzy all day and that she had not voided the entire day.

while catherine was getting into a hospital gown her medications fell out of her pocket. the nurse asked her if she was taking the medications but catherine did not reply. the nurse took the medications to the medical office and they both noted that the medications were:

prednisolone 25mg bd orally

medazine 1 gram bd orally

part two

further blood tests revealed:

prolactin 1211mu/l

cortisol 1066 nmol/l

protein 86 g/l

albumin 31.6 g/l

ggt 113 u/l

alt 36 u/l

it was noted by the nurse that catherine was previously on mesalazine 250 mg orally tds for ulcerative colitis. she discussed this with the medical officer who withdrew the order for medazine 1 gram and recommenced her on her previous dose of mesalazine

the medical officer reported that catherine to undertake a short synacthen test (sst).

[Daytonite, BSN, RN]

before you can do any interventions you have to look at all the data and determine what nursing problems you have going on. the case study is really nicely organized. what you need to do is make a list of all that data and look at it. doctors, as well as us nurses, will address (interventions) signs and symptoms that are abnormal. the most important in terms of priority have to do with those that affect the most important body systems first (see maslow's hierarchy of needs: http://en.wikipedia.org/wiki/maslow's_hierarchy_of_needs). to determine cause of her condition you have to look at all the symptoms and play doctor. what disease or condition do the symptoms seem to point to?

i would like you to attempt to work on this so i can see what you do know about the nursing process rather than me do all your work for you.

see https://allnurses.com/general-nursing-student/help-care-plans-286986.html- help with care plans for how to apply the steps of the nursing process in doing this assignment.

[lovelylia]

Thats just it ive been working on this thing for weeks and always seem to come to a dead end, ive got to the stage that im just so terribly frustrated and ive just gone blank.... any help would be much appreciated i have already started on it but i dont think its correct its too big to post here (13 - 14 pages).....

[Daytonite, BSN, RN]

Let me see the nursing diagnoses you came up with. That should take a few lines ande shoe me what signs and symptoms you felt were important.

[lovelylia]

Here is a bit if what ive done

Catherine was admitted 2 days ago through the emergency for collapse for investigation. Her BP was 75/not detectable, and had incomprehensible speech. Hypotension refers to an inadequate intravascular pressure to blood to maintain the oxygen requirements of the body’s tissues. Catherine’s symptoms of a sudden drop in blood pressure seem to correspond to that of what encompass an adrenal crisis, she has a past history of corticosteroid use due to an inflammatory bowel disorder. If stopped suddenly, or not reduced by appropriate tapering measures, the response may be the pituitary gland not producing enough ACTH. Prolonged use of corticosteroids causes adrenal glands to atrophy and therefore they need time to recover. These drugs have a direct effect on the adrenal glands; they decrease the amount of glucocorticoid and mineralcorticoid hormone that the body so desperately need to maintain blood pressure. A typical blood test result of an adrenal crisis which Catherine is displaying is low sodium levels.

Aldosterone belongs to a class of hormones called mineralorticoids, also produced by the adrenal glands, it helps maintain blood pressure and water and Na+ balance in the body by helping the kidney retain sodium and excrete potassium. When Na+ falls too low as in Catherines case the kidneys are not able to regulate Na+ and water balance, causing blood volume and blood pressure to drops. A sudden fall in BP could have contributed to her sudden collapse.

This could explain Catherine’s collapsing; the sudden drop in BP suggests there was not a sufficient amount of cerebral blood supply. Catherine’s BP was recorded once again in the emergency department but was till considerably low at 90/60. Catherine complained to the medical officer that she was still feeling dizzy this suggest that her low BP could be causing reduced blood and oxygen supply to the cerebrum which is making her feel dizzy. (Merk)

Nursing interventions:

Restoring fluid balance, select food high in Na+, administer medications as prescribed, until condition stabilized the nurse takes precautions to avoid unnecessary activity and stress that could precipitate another hypotensive episode. Monitor BP, to increase blood pressure.

Tachycardia

This is strongly relevant to Catherine’s hypotension as her heart rate suggests an increase in an attempt to deliver more oxygen to the cells of her body. When circulating volume decreases, the heart rate increases in an attempt to supply tissues with oxygen. Low circulatory volume can cause dry mucous membranes and increased thirst.

[Daytonite, BSN, RN]

Are you in the U.S?

[lovelylia]

no australia

[Daytonite, BSN, RN]

That may be the problem. Here in the U.S. we go for the nursing problems on these case studies, not the medical problems and manage patient care. We use the nursing process to do that. It's similar to how the doctors do their diagnosing, but I don't pretend to be a doctor or know how to diagnose medical conditions. I only know how to approach this from a nursing point of view the way we would do here in the U.S. That would be to identify the nursing problems and treat those. We may or may not be told the medical disease but be given hints about it, but our focus is always the nursing care primarily and assist the physician where necessary. Is that what you are supposed to do as well?

[lovelylia]

yes thats what we are supposed to do as well its just the way im trying to get this thing started is all wrong please help.....i havent slept all night just thinking about it

[Daytonite, BSN, RN]

using the nursing process to help organize this. . .

step #1 - organizing the assessment data - assesment consists of:

• a health history (review of systems) - this is a 22 year old unemployed single mother admitted 2 days ago through emergency department for collapse with her two-year old unkempt child at her side. blood pressure was 75 mmhg/not detectable, speech incomprehensible at first but later became slurred, all limbs equal in power, pupils were equal and reacting to light. only family history obtainable is that she has had ulcerative colitis for 6 years and had an ileoanal anastomosis 14 months ago.
  
• performing a physical exam - (we are only interested in what is abnormal for problem solving and care planning) temperature 360c (what?), bp now 90/60, respirations 22 breaths per minute, pulse 130 beats per minute, weight 45kg, height 160 cm, bruises to lower limbs and patient report of feeling nauseous and dizzy all day and that she had not voided the entire day
  
• assessing their adls (at minimum: bathing, dressing, mobility, eating, toileting, and grooming)
  
• reviewing the pathophysiology, signs and symptoms and complications of their medical condition - look up information about syncope which is what brought her to the er and ulcerative colitis. some of her labs are also really out of whack and need to be explained.
  
• reviewing the signs, symptoms and side effects of the medications/treatments that have been ordered and that the patient is taking - labs: bgl 7.2 mmol, sodium 124 mmol/l, hb 116 g/l, potassium 5.2 mmol/l, hct 0.38l/l, chloride 89 mmol/l, rcc 4.8 x 1012/l, bicarbonate 23 mmol/l, mcv 78 fl, anion gap 17, wcc 16 x 109/l, urea 10.3 mmoml/l, esr 34 mm/hr, creatinine 0.12 mmol/l, crp 31 mg/l, prolactin 1211mu/l, cortisol 1066 nmol/l, protein 86 g/l, albumin 31.6 g/l, ggt 113 u/l and alt 36 u/l. medications: prednisolone 25mg bd orally and medazine 1 gram bd orally and previous order for mesalazine (what clues do these medications provide?). to have a short synacthen test (sst).
  

step #2 - determining the nursing problems - this is done by studying the abnormal data above. i really didn't go through it that carefully. the question of why she passed out and collapsed needs to be addressed. her dehydration may be a result of diarrhea. you may be meant to determine that based on the lab results and medications she were told about. the issue of her cortisol is also at issue since another disease seems to be a possible problem here as well. she has skin integrity problems (the bruises) and the condition of her child needs to be investigated. there are social and possibly financial problems here. here in the u.s. child protective services would have been called in (by mandatory law) and that child would probably have been put in a foster home for care while an investigation was done. my guess: this lady came from an abusive relationship.

what are some of the nursing problems you identified? you shouldn't be getting into the nursing interventions until you have done a thorough discussion and analysis of the assessment data and how they lead you to the problems that are present. the abnormal data are what support your nursing problems because they are the supporting evidence of them. some of them also become the things you will be able to treat and target for some of your interventions. i talk about this sequence of care planning on this thread: https://allnurses.com/general-nursing-student/help-care-plans-286986.html- help with care plans all the time.

[lovelylia]

i organized the assessment data but still keep coming to a mental block, everything points to renal insufficencly then i cant explain the high cortisol levels im at a complete loss

[Daytonite, BSN, RN]

i can advise that you use the nursing process to organize the case study. i think it is wrong for nurses to be asked to medically diagnose. i can tell you to check lab sites to advise you what high cortisol levels usually mean. my lab reference book states this with regard to the significance of increased cortisol levels:

• cushing's disease
  
• adrenal carcinoma
  
• ectopic acth producing tumors
  
• hyperthyroidism
  
• obesity
  
• stress
  

it could be any one of those as well. there may be no answer, just possibilities that you are to discuss in a scholarly way. you might check with your instructor about this. it looks like the docs don't know what is going on either, so they are going to investigate which is appropriate on their part: http://www.dundee.ac.uk/medther/tayendoweb/images/short_synacthen_test.htm. some things remain mysteries and that is ok, just not for the patient. we can only do so much with the information we have to work with. stress due to her being beat up and having ulcerative colitis may also have something to contribute to the elevated cortisol levels in this person's unfortunate situation.