What are FOUR nursing diagnoses for this case study based on Maslow's Hierachy of needs. - state any relevant data to su

[answerhappygod]

What are FOUR nursing diagnoses for this
case study based on Maslow's Hierachy of
needs.
- state any relevant data to support
the diagnosis
CASE STUDY:
- Admitted from the ER yesterday for n/v, diarrhea, as well as
RUQ abdominal pain.
- 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.
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
Resident type: apartment
Lives with: significant other and son
Animals: 3 guinea pigs, cat
Significant other(s): boyfriend
Past Medical History
Anemia
Anxiety and depression
Asthma
IBS
Hyperlipidemia
Hypertension
Hypothyroidism
Osteoarthritis
Umbilical Hernia
Past surgery
Bariatric surgery (3 weeks s/p)
Medications on unit
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/Ipratropium 3mL inhaled once, PRN
General appearance
Appearance: Good
Height: 1.6m
Weight: 105kg
BMI: 41
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
Fatigue: mild
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
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
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
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
Devices: toilet
Psychosocial / Spiritual
Mood: calm
Affect: appropriate
Manner: cooperative
Intellectual abilities: clear, linear
Memory: Intact
Support System: boyfriend, best friend
What is your occupation? Disabled
Diagnostics: Hematology
Everything else is WNL
MCH: 25.5 (LOW)
MCHC: 30.8 (LOW)
RDW: 17.8 (HIGH)
Diagnostics: Chemistry
Everything else is WNL
Total Protein: 6.1 (LOW)
Albumin: 3.7 (LOW)
Alkaline Pho: 111 (HIGH)
AST: 14 (LOW)
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
subjective data:
patient states she "cannot wait to leave after discharge and
eat a real meal"
patient is "craving coffee"
patient "can't wait to play with her pets"