Please help me answer the questions below. Thank you so much for your help!! Case Study #5 William Borrows is a 23-year-
Posted: Mon Jul 11, 2022 2:26 pm
Please help me answer the questions below. Thank you so much foryour help!!
Case Study #5
William Borrows is a 23-year-old male of Chinese descent. He isa recent immigrant to the US, just recently moved here from Chinathree months ago. William works in the IT industry and lives in asmall studio apartment. He sends all of his extra money home sothat he can help move his family here to the US one by one. HisEnglish is functional, but he is still uncomfortable speaking thelanguage. He asked one of the ER nurses to please call his templeso that one of the Monks can come and visit him in hospital becausehe is afraid that he may have done something bad to someone andthat is why he has gotten sick.
William showed up at the ER three days ago complaining of rightupper quadrant abdominal pain 6/10 that increased after meals.Williams last bowel movement was 2 days before he came into the ER.William decided to come to the ER after he started vomiting aftereating. William was admitted to the hospital with a diagnosis ofgallstones.
William’s vital signs are: HR 99 BP 139/76 RR 22 O2 99 Temp 99.8Pain 8/10
Williams labs were as follows:
Labs: WBC 15 AST 80 ALT 97 Amylase 98 Lipase 250
Abdominal ultrasound: revealed gallstones
HIDA scan revealed that there is a blockage in the gallbladderpreventing clearance, solidifying dx of gallstones
ERCP revealed that the ducts from the gallbladder areblocked.
William has undergone a cholecystectomy without anycomplications. On waking William was complaining of pain 8/10 andDilaudid was given. This brought William’s pain down to 2/10 whichWilliam reports as tolerable.
While hospitalized the orders for William are as follows:
Diet- high fiber
Medications- Dilaudid 0.5mg IV q2h PRN pain greater than5/10
Tylenol 650mg PO q6h PRN pain between 1-4/10
Zofran 4mg IV q6h PRN nausea
Zosyn 3.75 gm q6h IV
NS 75ml/hr IV continuous
Ambulate after surgery
Schedule GI follow up 1 week post discharge
By 8 hours post surgery William had no bowel sounds and hisabdomen was distended. William was stating his pain was 10/10. Thesurgeon was called to assess William and he was diagnosed withparalytic ileus and was admitted for another 3 days.
Doctors orders were as follows:
NG tube insertion, intermittent suction for 24 hours, removeafter 24 hours
NPO diet.
Once NG tube is removed, slowly increase diet as tolerated.
William has a medical history of asthma (ProAir MDI 90mcg 2puffsPRN q2h SOB), urinary retention post hypospadias correction as achild so he self-caths every 4 hours or as needed, right humoralfracture as a teenager with ORIF
1.
Assessment: What are theidentified abnormal findings:
______________________________________________________________________________________
2.
Analysis/Hypothesis: What is thecause of the patients problem that must be prioritized at thistime?
_________________________________________________________________________________________
3.
Planning (Patient goals focus on resolvingthe problem), Must be SMARTgoals Generate Solutions
Develops a list of actions to address the priorityhypothesis.
by the: (end of shift, end of day, discharge day) orwithin: (two hours; 12 hours, etc.)
4.
Implementation (Specific nursinginterventions that were performed duringyour shift): Take Action
Must contain thefollowing: Assess {observe, auscultate,palpate, percuss}; Monitor; Prepare, administer;Collaborate w/ specific multi-disciplinary team;& teach, i.e., VERBS
5. Evaluation (What was the outcome: Did you meet yourdesired goal?) Do your interventions address furthermonitoring of the patient’s response to your interventions and tothe achievement of the desired outcome?
Goal; Met or Not met or partially met ?
Case Study #5
William Borrows is a 23-year-old male of Chinese descent. He isa recent immigrant to the US, just recently moved here from Chinathree months ago. William works in the IT industry and lives in asmall studio apartment. He sends all of his extra money home sothat he can help move his family here to the US one by one. HisEnglish is functional, but he is still uncomfortable speaking thelanguage. He asked one of the ER nurses to please call his templeso that one of the Monks can come and visit him in hospital becausehe is afraid that he may have done something bad to someone andthat is why he has gotten sick.
William showed up at the ER three days ago complaining of rightupper quadrant abdominal pain 6/10 that increased after meals.Williams last bowel movement was 2 days before he came into the ER.William decided to come to the ER after he started vomiting aftereating. William was admitted to the hospital with a diagnosis ofgallstones.
William’s vital signs are: HR 99 BP 139/76 RR 22 O2 99 Temp 99.8Pain 8/10
Williams labs were as follows:
Labs: WBC 15 AST 80 ALT 97 Amylase 98 Lipase 250
Abdominal ultrasound: revealed gallstones
HIDA scan revealed that there is a blockage in the gallbladderpreventing clearance, solidifying dx of gallstones
ERCP revealed that the ducts from the gallbladder areblocked.
William has undergone a cholecystectomy without anycomplications. On waking William was complaining of pain 8/10 andDilaudid was given. This brought William’s pain down to 2/10 whichWilliam reports as tolerable.
While hospitalized the orders for William are as follows:
Diet- high fiber
Medications- Dilaudid 0.5mg IV q2h PRN pain greater than5/10
Tylenol 650mg PO q6h PRN pain between 1-4/10
Zofran 4mg IV q6h PRN nausea
Zosyn 3.75 gm q6h IV
NS 75ml/hr IV continuous
Ambulate after surgery
Schedule GI follow up 1 week post discharge
By 8 hours post surgery William had no bowel sounds and hisabdomen was distended. William was stating his pain was 10/10. Thesurgeon was called to assess William and he was diagnosed withparalytic ileus and was admitted for another 3 days.
Doctors orders were as follows:
NG tube insertion, intermittent suction for 24 hours, removeafter 24 hours
NPO diet.
Once NG tube is removed, slowly increase diet as tolerated.
William has a medical history of asthma (ProAir MDI 90mcg 2puffsPRN q2h SOB), urinary retention post hypospadias correction as achild so he self-caths every 4 hours or as needed, right humoralfracture as a teenager with ORIF
1.
Assessment: What are theidentified abnormal findings:
______________________________________________________________________________________
2.
Analysis/Hypothesis: What is thecause of the patients problem that must be prioritized at thistime?
_________________________________________________________________________________________
3.
Planning (Patient goals focus on resolvingthe problem), Must be SMARTgoals Generate Solutions
Develops a list of actions to address the priorityhypothesis.
by the: (end of shift, end of day, discharge day) orwithin: (two hours; 12 hours, etc.)
4.
Implementation (Specific nursinginterventions that were performed duringyour shift): Take Action
Must contain thefollowing: Assess {observe, auscultate,palpate, percuss}; Monitor; Prepare, administer;Collaborate w/ specific multi-disciplinary team;& teach, i.e., VERBS
5. Evaluation (What was the outcome: Did you meet yourdesired goal?) Do your interventions address furthermonitoring of the patient’s response to your interventions and tothe achievement of the desired outcome?
Goal; Met or Not met or partially met ?