4 NURSING DIAGNOSES for this case study in order based on Maslow's Hierachy of needs. - state any relevant data to suppo
Posted: Tue Mar 15, 2022 2:48 pm
4 NURSING DIAGNOSES for this case study in order
based on Maslow's Hierachy of needs.
- state any relevant data to support the
diagnosis
CASE STUDY:
Day 1 notes
- 39 year old female with a past medical hx for anemia, anxiety,
depression, asthma, IBS, hyperlipidemia, hypertension,
hypothyroidism, morbid obesity, osteoarthritis, and an umbilical
hernia as well as about 3 weeks status post robotic sleeve
gastrectomy.
- Admitted from the ER for n/v, diarrhea, as well as RUQ
abdominal pain.
Day 2 notes
Physical:
- She had RUQ pain with a postive Murphy's sign. Hida scan with
CCK positive for 0% ejection fraction. Plans were made for robotic
assisted laparoscopic cholecystectomy.
- Patient underwent the procedure yesterday. Patient tolerated
the procedure well. She was extubated and brought the post-op floor
to resume recovery.
- Patient restarted on bariatric stage II diet. She is
tolerating her diet well. She has no nausea or vomiting, or
diarrhea. Also no RUQ pain.
- Independently voiding and ambulating
Discharge plan
- Home today without services
- May advance her bariatric diet to stage III as scheduled
on her bariatric plan
ASSESSMENT:
Date admitted: 3/8/2022
Chief complaint: abdominal pain, n/v, diarrhea
Medical Diagnosis: Cholecystitis
Background info:
- Patient had RUQ pain with a positive Murphy's sign. Hida scan
with CCK positive for 0% ejection fraction. Plans were made for
robotic assisted laparoscopic cholecystectomy. Patient underwent
the procedure yesterday and tolerated the procedure well. She was
extubated and brought to the post-op floor to resume recovery. She
has no nausea or vomiting, or diarrhea. Also no RUQ pain.
Related surgery and date: robotic assisted laparoscopic
cholecystectomy 3/9/2022
Age: 39
Gender: Female
Allergies: Penicillin, sulfa, tetanus vaccines and
toxoids, morphine, codeine, naproxen, oranges
Code status: Full
Advanced directive: none
Resident type: apartment
Lives with: significant other and son
Animals: 3 guinea pigs, cat
Significant other(s): boyfriend
Education level: not assessed
Past Medical History
Anemia
Anxiety and depression
Asthma
IBS
Hyperlipidemia
Hypertension
Hypothyroidism
Osteoarthritis
Umbilical Hernia
Past surgery
C-section
Bariatric surgery (3 weeks s/p)
Medications on unit
Tramadol 50mg PO q6h PRN (moderate pain 4-6)
Ondansetron 4mg PO q8h (nausea/vomit)
Labetalol 50mg PO BID
Lamotrigine 150mg PO BID
Dextroamphetamine 10mg PO QHS
Ropinirole 0.5mg PO QHS
Levothyroxine 50mcg PO daily at 0600
Pentaprazole 40mg PO daily at 0600
Venlafaxine 225mg PO daily
Acetaminophen 650mg PO q6h PRN (mild pain 1-3)
Albuterol Sulfate 2.5mg/3mL NEB PRN
Albuterol/Ipratropium 3mL inhaled once, PRN
General appearance
Appearance: Good
Height: 1.6m
Weight: 105.233 kg
BMI: 41.1
Build: morbid obese
ADL's: self
Precautions: standard, fall prevention, bleeding
Vitals: temp: 97.9F, pulse: 77, RR: 18, BP: 142/78, O2Sat:
96% RA. @ 1130
Pain
Level: 7/10
Location: at incision site
Quality: sharp, throbbing, shooting
Duration: hours
Frequency: constant
Precipitating factors: sitting for extended periods of time
Alleviating factors: meds, heat, warm blankets, change
positions, rest
Time: 1100
Reassess: 1200
Respiratory
O2 Sat: 96% RA
Resp Rate: 18
Quality: non-labored
Pattern: regular
Lung sounds: clear
Location of lung sounds: throughout
Symmetry: equal
Nail beds: pink
Sputum: n/a
Dyspnea: n/a
Fatigue: mild
Head
Color of sclera: white
Mucus Membranes: clear
Mouth odor: none noted
Condition of teeth: good, no noticeable cracks or stains
Lesions of mouth: none
Discharge: none
Neck
Neck masses: no
Facial edema: no
Trachea alignment: center
Cardiovascular
Heart Rhythm: regular
Heart rate: 77 (normal)
Heart sounds: S1 + S2
Blood pressure: 142/78
Apical pulse: n/a
Capillary refill: < 3 seconds
Peripheral pulses: +2
Edema: none
Dizziness/Syncope: none reported
IV fluid type and mls/hour: /
IV intake mls/shift: /
Neurovascular/Sensory
LOC: awake
Orientation: A&O x4
Pupils: reactive
Vision: clear
Hearing: normal
Grasp: even, firm
Strength: normal for patient
Speech: clear
Circulation: no cyanosis or pallor
Motion: smooth movements
Sensation: present
Other cranial nerves: /
Gastrointestinal
Bowel sounds: positive all 4 quadrants
Abdomen description: soft, non-distended
Diet: Bariatric stage II
Appetite: hungry
Nausea: none
Stool: n/a
Pattern: constipation
Date of last BM: 03/09
Devices: toilet
PO/GT/NGT/(other) Intake: PO, ate eggs and decaf coffee
Integumentary Skin
Temperature: warm
Turgor: elastic
Color: normal for patient
Moisture: dry
Braden Scale: 18
Scars: none noted
Wounds: 4 abdominal laparoscopy incisions
Irritations: none
Lesions: none noted
Insertion type and Site(s): 20g on Right hand
Musculoskeletal
Mobility strength: independent
Upper strength: normal for patient
Lower: normal for patient
Posture: sits upright
Symmetry: symmetrical
Gait: n/a
Balance: n/a
Range of Motion: full ROM
Assistive device(s): none
Genitourinary
Color: yellow
Odor: none noted
Urine output (ml/shift): /
LMP/menopausal: /
Drainage: none noted
Incontinence: n/a
Devices: toilet
Cultural Assessment
Is your culture important to you?: n/a
What is your religion?: Christian
Is it important to you?: n/a
Are there healthcare practices from your culture that are
important?: no
Psychosocial / Spiritual
Mood: calm
Affect: appropriate
Manner: cooperative
Thought processes: none
Intellectual abilities: clear, linear
Memory: Intact
Support System: boyfriend, best friend
What is your occupation? Disabled
Based on the cultural assessment, what are the implications for
nursing care?: n/a
Diagnostics: Hematology
WBC: 4.6
RBC: 4.66
Hgb: 11.99
Hct: 38.6
MCV: 82.8
MCH: 25.5 (LOW)
MCHC: 30.8 (LOW)
% Neutrophils: 45.4
% Lymphs: 41.5
% Mono: 6.7
% Eos: 4.8
% Baso: 1.3
Neutrophil: 2.1
Lymphs: 1.0
Mono: 0.3
Eos: 0.2
Baso: 0.1
RDW: 17.8 (HIGH)
Platelet: 216
MPV: n/a
Diagnostics: Chemistry
Sodium: 141
Potassium: 3.8
Chloride: 103
CO2: 26
Glucose: 1.2
BUN: 8
Creatinine: 0.7
B/C Ratio: 11.4
Calcium: 8.6
Phosphorus: n/a
Uric Acid: n/a
Total Protein: 6.1 (LOW)
Albumin: 3.7 (LOW)
Globulin: n/a
A/G ratio: n/a
Total Bili: 0.2
Alkaline Pho: 111 (HIGH)
AST: 14 (LOW)
ALT: 16
Amylase/Lipase: n/a
Doctor’s orders:
Full code
ADT - Discharge routine
Diet - Bariatric Surgical diet (lunch)
Consult - Spiritual care consultation
Med - Tramadol (discontinue) 1301, Oxycodone 10mg PO q4h PRN
(discontinue) 0910, Acetaminophen 600m PO q6h PRN (discontinue)
1301
based on Maslow's Hierachy of needs.
- state any relevant data to support the
diagnosis
CASE STUDY:
Day 1 notes
- 39 year old female with a past medical hx for anemia, anxiety,
depression, asthma, IBS, hyperlipidemia, hypertension,
hypothyroidism, morbid obesity, osteoarthritis, and an umbilical
hernia as well as about 3 weeks status post robotic sleeve
gastrectomy.
- Admitted from the ER for n/v, diarrhea, as well as RUQ
abdominal pain.
Day 2 notes
Physical:
- She had RUQ pain with a postive Murphy's sign. Hida scan with
CCK positive for 0% ejection fraction. Plans were made for robotic
assisted laparoscopic cholecystectomy.
- Patient underwent the procedure yesterday. Patient tolerated
the procedure well. She was extubated and brought the post-op floor
to resume recovery.
- Patient restarted on bariatric stage II diet. She is
tolerating her diet well. She has no nausea or vomiting, or
diarrhea. Also no RUQ pain.
- Independently voiding and ambulating
Discharge plan
- Home today without services
- May advance her bariatric diet to stage III as scheduled
on her bariatric plan
ASSESSMENT:
Date admitted: 3/8/2022
Chief complaint: abdominal pain, n/v, diarrhea
Medical Diagnosis: Cholecystitis
Background info:
- Patient had RUQ pain with a positive Murphy's sign. Hida scan
with CCK positive for 0% ejection fraction. Plans were made for
robotic assisted laparoscopic cholecystectomy. Patient underwent
the procedure yesterday and tolerated the procedure well. She was
extubated and brought to the post-op floor to resume recovery. She
has no nausea or vomiting, or diarrhea. Also no RUQ pain.
Related surgery and date: robotic assisted laparoscopic
cholecystectomy 3/9/2022
Age: 39
Gender: Female
Allergies: Penicillin, sulfa, tetanus vaccines and
toxoids, morphine, codeine, naproxen, oranges
Code status: Full
Advanced directive: none
Resident type: apartment
Lives with: significant other and son
Animals: 3 guinea pigs, cat
Significant other(s): boyfriend
Education level: not assessed
Past Medical History
Anemia
Anxiety and depression
Asthma
IBS
Hyperlipidemia
Hypertension
Hypothyroidism
Osteoarthritis
Umbilical Hernia
Past surgery
C-section
Bariatric surgery (3 weeks s/p)
Medications on unit
Tramadol 50mg PO q6h PRN (moderate pain 4-6)
Ondansetron 4mg PO q8h (nausea/vomit)
Labetalol 50mg PO BID
Lamotrigine 150mg PO BID
Dextroamphetamine 10mg PO QHS
Ropinirole 0.5mg PO QHS
Levothyroxine 50mcg PO daily at 0600
Pentaprazole 40mg PO daily at 0600
Venlafaxine 225mg PO daily
Acetaminophen 650mg PO q6h PRN (mild pain 1-3)
Albuterol Sulfate 2.5mg/3mL NEB PRN
Albuterol/Ipratropium 3mL inhaled once, PRN
General appearance
Appearance: Good
Height: 1.6m
Weight: 105.233 kg
BMI: 41.1
Build: morbid obese
ADL's: self
Precautions: standard, fall prevention, bleeding
Vitals: temp: 97.9F, pulse: 77, RR: 18, BP: 142/78, O2Sat:
96% RA. @ 1130
Pain
Level: 7/10
Location: at incision site
Quality: sharp, throbbing, shooting
Duration: hours
Frequency: constant
Precipitating factors: sitting for extended periods of time
Alleviating factors: meds, heat, warm blankets, change
positions, rest
Time: 1100
Reassess: 1200
Respiratory
O2 Sat: 96% RA
Resp Rate: 18
Quality: non-labored
Pattern: regular
Lung sounds: clear
Location of lung sounds: throughout
Symmetry: equal
Nail beds: pink
Sputum: n/a
Dyspnea: n/a
Fatigue: mild
Head
Color of sclera: white
Mucus Membranes: clear
Mouth odor: none noted
Condition of teeth: good, no noticeable cracks or stains
Lesions of mouth: none
Discharge: none
Neck
Neck masses: no
Facial edema: no
Trachea alignment: center
Cardiovascular
Heart Rhythm: regular
Heart rate: 77 (normal)
Heart sounds: S1 + S2
Blood pressure: 142/78
Apical pulse: n/a
Capillary refill: < 3 seconds
Peripheral pulses: +2
Edema: none
Dizziness/Syncope: none reported
IV fluid type and mls/hour: /
IV intake mls/shift: /
Neurovascular/Sensory
LOC: awake
Orientation: A&O x4
Pupils: reactive
Vision: clear
Hearing: normal
Grasp: even, firm
Strength: normal for patient
Speech: clear
Circulation: no cyanosis or pallor
Motion: smooth movements
Sensation: present
Other cranial nerves: /
Gastrointestinal
Bowel sounds: positive all 4 quadrants
Abdomen description: soft, non-distended
Diet: Bariatric stage II
Appetite: hungry
Nausea: none
Stool: n/a
Pattern: constipation
Date of last BM: 03/09
Devices: toilet
PO/GT/NGT/(other) Intake: PO, ate eggs and decaf coffee
Integumentary Skin
Temperature: warm
Turgor: elastic
Color: normal for patient
Moisture: dry
Braden Scale: 18
Scars: none noted
Wounds: 4 abdominal laparoscopy incisions
Irritations: none
Lesions: none noted
Insertion type and Site(s): 20g on Right hand
Musculoskeletal
Mobility strength: independent
Upper strength: normal for patient
Lower: normal for patient
Posture: sits upright
Symmetry: symmetrical
Gait: n/a
Balance: n/a
Range of Motion: full ROM
Assistive device(s): none
Genitourinary
Color: yellow
Odor: none noted
Urine output (ml/shift): /
LMP/menopausal: /
Drainage: none noted
Incontinence: n/a
Devices: toilet
Cultural Assessment
Is your culture important to you?: n/a
What is your religion?: Christian
Is it important to you?: n/a
Are there healthcare practices from your culture that are
important?: no
Psychosocial / Spiritual
Mood: calm
Affect: appropriate
Manner: cooperative
Thought processes: none
Intellectual abilities: clear, linear
Memory: Intact
Support System: boyfriend, best friend
What is your occupation? Disabled
Based on the cultural assessment, what are the implications for
nursing care?: n/a
Diagnostics: Hematology
WBC: 4.6
RBC: 4.66
Hgb: 11.99
Hct: 38.6
MCV: 82.8
MCH: 25.5 (LOW)
MCHC: 30.8 (LOW)
% Neutrophils: 45.4
% Lymphs: 41.5
% Mono: 6.7
% Eos: 4.8
% Baso: 1.3
Neutrophil: 2.1
Lymphs: 1.0
Mono: 0.3
Eos: 0.2
Baso: 0.1
RDW: 17.8 (HIGH)
Platelet: 216
MPV: n/a
Diagnostics: Chemistry
Sodium: 141
Potassium: 3.8
Chloride: 103
CO2: 26
Glucose: 1.2
BUN: 8
Creatinine: 0.7
B/C Ratio: 11.4
Calcium: 8.6
Phosphorus: n/a
Uric Acid: n/a
Total Protein: 6.1 (LOW)
Albumin: 3.7 (LOW)
Globulin: n/a
A/G ratio: n/a
Total Bili: 0.2
Alkaline Pho: 111 (HIGH)
AST: 14 (LOW)
ALT: 16
Amylase/Lipase: n/a
Doctor’s orders:
Full code
ADT - Discharge routine
Diet - Bariatric Surgical diet (lunch)
Consult - Spiritual care consultation
Med - Tramadol (discontinue) 1301, Oxycodone 10mg PO q4h PRN
(discontinue) 0910, Acetaminophen 600m PO q6h PRN (discontinue)
1301