CASE STUDY - Macy Bundy Comprehensive Case Study 1 Case...

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Macy Bundy Comprehensive Case Study 1 Case Study Macy Bundy Nursing 863:002 11/08/2007
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Macy Bundy Comprehensive Case Study 2 M.S. is a 58 year old Caucasian female who arrived at Cardinal Hill Rehabilitation Hospital (CHRH) on October 12, 2007 for rehabilitation post surgery at St. Joseph Hospital. Dr. B.S admitted the patient for Physical Therapy (PT) and Occupational Surgery (OT) after her C2-C7 Anterior Posterior fusion in late September. Specific admitting diagnosis per provider includes multiple rehabilitation therapy, other malaise & fatigue, surgical after care, Rheumatoid Arthritis, dysphagia, below the knee amputation (BKA), Atrial Fibrillation (a-fib), Osteoporosis, anemia, reflux, and hiatal hernia. Past medical history includes a right below the knee amputation, blood transfusions, multiple joint replacement, hysterectomy, cancer, hypertension (HTN), blood transfusions, malaise and fatigue, GERD, cataracts, and Juvenile Rheumatoid Arthritis (JRA). Prior to surgery M.S. independently lived at her home in Midway, KY with a pet cat. She was diagnosed at age 16 with JRA which has progressed over her life and has just recently enabled her to do things she enjoys including painting, gardening, and playing the piano. With the progressiveness of her disease M.S. has also had the ability to be mobile and to perform activities of daily living (ADLs) taken from her. Respiratory M.S. has no history of respiratory distress. At 18/min and regular her respiratory rate, depth, quality and rhythm are all within the normal parameters. M.S. is at risk for impaired respiratory function related to immobility secondary to surgery (Carpenito-Moyet, 2006). She displays symmetrical shallow, thoracic breathing, with the presents of nasal flaring. Her diagnostic tests related to respiratory function include 11.4 for hemoglobin (Normal: 12-15) and 35 for Hematocrit (Normal: 35-45). Decreased levels of hemoglobin indicate anemia or a reduced amount of red blood cells (Pagana and Pagana, 2007 p. 521). This seems possible due to the blood transfusions she had through her lifetime, as well as, the lack of red meat she eats which she verbalized to the nurse. It may be wise for the doctors to implement a diet high in iron, pyridoxine, folate, vitmin B12, and protein to help raise her hemoglobin (Harkreader, Hogan, and Thobaben, 2007, p. 591) or it may be beneficial to include another multi-vitamin besides the Multivitamins Liquid: 1tsp/5ml- PO she already is taking. These vitamins are used in the prevention and
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Macy Bundy Comprehensive Case Study 3 treatment of vitamin deficiencies and as supplements in various metabolic disorders. Severe side effects include sypersensitivity to additives, preservatives, or colorants. Patients on this should be monitored for dosage to avoid toxicity, should be monitored for deficiencies and nutritional status (Deglin and Vallerand, 2007). Due to the client’s recent surgery, as well as, her current immobility, incentive spirometery may become a necessary intervention the health care team will need to put into action. In the
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This note was uploaded on 04/23/2008 for the course NURSING Nursing taught by Professor Nursing during the Spring '08 term at Kentucky.

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CASE STUDY - Macy Bundy Comprehensive Case Study 1 Case...

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