Quick Case Study- Please help!

Published

I am taking my foundations final next week and part of it deals with case studies. I really need to do well on this test so I would greatly appreciate the help. She gave us a bunch to practice with but I am having trouble with the following:

Yolanda is a 54 year-old female who is 5'3" and weighs 255 pounds. She is marries, a homemaker, and has 3 grown children. SHe presents at the clinic after four days of having "flu-like symptoms" including vomiting, diarrhea, and complaints of aches in her back. The nurse assesses the following: Active bowel sounds, reports of 2-3 loose stools each day for the past 3 days, and comiting at least once each day. Her appetite is decreased and she has taken limited fluids. Her vital signs are temperature 98.9F, pulse 108, respirations 16, and blood pressure 148/88.

We are supposed to be looking for nursing diagnoses with these. I would assume that dehydration (fluid volume defecit??) is going to be a problem for her from losing so much fluid. Does anyone have any other ideas? Thanks!

Up Vote Up Vote ×
Specializes in med/surg, telemetry, IV therapy, mgmt.

All the abnormal information you are given should be considered as part of your assessment and determination of nursing problems:

  • weighs 255 pounds (obesity)
  • four days of having "flu-like symptoms" including vomiting, diarrhea, and complaints of aches in her back
  • reports of 2-3 loose stools each day for the past 3 days
  • vomiting at least once each day
  • appetite is decreased
  • she has taken limited fluids
  • pulse 108

Nursing diagnoses that apply to the above are:

  • Imbalanced Nutrition: more than body requirements
  • Imbalanced Nutrition: less than body requirements
  • Nausea
  • Diarrhea
  • Acute Pain
  • Risk for Deficient Fluid Volume

Up Vote Up Vote ×

Thank you very much. So would you say there in the short term there is a risk for imbalanced nutrition less that body requirements due to her disease process but in the long term there is risk for more than body requirements due to her weight?

I am terrible at these!

Up Vote Up Vote ×
Specializes in med/surg, telemetry, IV therapy, mgmt.

That sounds reasonable.

Up Vote Up Vote ×
+ Join the Discussion