Help me out if you can! I'm at disagreement with my teacher over what the nursing diagnosis is for the patient below. Now I don't want to give the answer away for fear of revealing to much, but I promise that I've already faced the repercussions for the Nursing Diagnosis that I made. Thank you for your input and I look forward to your response.
Thanks, E
Mrs. S. is a 28 y.o. African American female admitted to your floor with c/o RUQ (Right upper quadrant) abdominal pain, fever, and Rt. Shoulder pain. Mrs. S. states this started gradually 2 days ago but got worst last night. She rates the pain 9/10 and describes it as an aching pain that is constant. She denies any activity that could of brought it on. It is worst when she rides in a car and goes over bumps in the road. Mrs. S. tried taking Ibuprofen 200mg every 4 hours for the pain with slight relief. Her PMH includes Hypertension. Her current medications include Norvasc 5mg everyday & Lotensin 20mg everyday. Her LMP (last menstrual period) was 1/1/08. Her husband is away in Iraqand she has not been sexually active for 4 months since he was last home. Mrs. S. denies smoking cigarettes or using drugs. She admits to an occasional glass of wine. She was given Demerol 75mg and Phenergan 25mg IM in the ER about 2 hours ago. Her pain has decreased to a 6/10. The ER physician has her scheduled for an ultrasound of the abdomen. Her recent blood work in the ER showed to be normal except for an elevated WBC (white blood cell count) of 15. Her VS are 100.1, 85, 12, & 140/70. Wt. 205# & Ht. 5'5†Lungs are clear to auscultation & percussion. Heart is regular rate with normal S1 & S2. Abdomen is tender over the RUQ with guarding. Bowel sounds are present x 4 quadrants
As people have mentioned, a fever isn't considered a fever until it is 100.4, and even then, that is pretty low. As you say "pain is subjective," but you also mentioned you wouldn't give a patient pain meds because they were just given them (perhaps an hour or two prior)? In the ED, we are regularly giving patients pain medications.
Remember that pain is also a vital sign.
I think the fact that this patient has RUQ pain that radiates to the shoulder is the key here and I don't believe you are even paying attention to it. You're so fixated on the temperature that you completely oversaw a subjective assessment.
please can you help me out with nursing diagnosis for this case study!!
Kathie is a 30-year-old G1 P0 with no medical history admitted to the hospital at 39 weeks of gestation in early active labor. Her cervical examination is 3/100/-1 vertex. Her membranes are intact. Her contractions are every 4 minutes × 60 seconds. Fetal heart tones are 140 with moderate variability, accelerations present, and no decelerations. She declines medication for pain at this time, but states she might want something later. Her partner is at the bedside and appears anxious.
Write a priority nursing care plan for Kathie taking into account that this is her first pregnancy.
What are your thoughts? Just finished covering this in my class and have a few different things I could think of. What have you learned about FHM, what may you be able to teach the parents. What can you teach her and her support person about pain management?
Pardon me if I go back 34 years. I was dazed and confused with the minimal guidance I received from both classroom lecturers and clinical instructors. OP is trying.. needs assistance from us, as she is NOT getting it in the real world.
Thank you for this, Been there, done that! I don't think things have changed much.
Kuriin, BSN, RN
967 Posts
As people have mentioned, a fever isn't considered a fever until it is 100.4, and even then, that is pretty low. As you say "pain is subjective," but you also mentioned you wouldn't give a patient pain meds because they were just given them (perhaps an hour or two prior)? In the ED, we are regularly giving patients pain medications.
Remember that pain is also a vital sign.
I think the fact that this patient has RUQ pain that radiates to the shoulder is the key here and I don't believe you are even paying attention to it. You're so fixated on the temperature that you completely oversaw a subjective assessment.
Anyhow...good luck in the class.