Med/Surg - Case Study Help!

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, coorifice 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.