Nursing Care Plan Case Study CHIEF COMPLAINT:  "I'm passing black...

Nursing Care Plan Case Study

CHIEF COMPLAINT: "I'm passing black stool" and lightheadedness - 3 days. 

HISTORY OF PRESENT ILLNESS: Mr. Murphy is a 45-year-old advertising executive who presents to the emergency room complaining of the passage of black stools x 3 days and associated lightheadedness. He also relates that he cannot keep up with his usual schedule because of fatigue and only sleeps about 3 hours at night. Upon further questioning, he states that his stools are not only black but are sticky and malodorous. He further complains of recent worsening of a chronic epigastric burning, which had been a problem off/on for years. He had doubled his usual dose of tums without significant relief of the burning. He has 2-3 martinis at lunch and another cocktail before dinner. He takes NSAIDS as needed for back pain and recently started on one aspirin per day for cardiac prophylaxis. He smokes two packs of cigarettes per day and an occasional cigar. He was told of an ulcer in the distant past but had no specific evaluation or treatment for the same. 

Mr. Murphy has been treated for hypertension for eight years but denies any known cardiac history. His weight is stable to increased, and he claims to have an excellent appetite. He has a normal bowel habit and has not had prior black stools. He has had no abdominal surgery and denies bleeding tendencies or prior transfusion.

He is married and has four children; two of them are in college, and two are at home. He was a long-distance runner and wished he could compete in running events as he did in the past. He states somewhat silently, "I used to do so many things with my children." "My life has not been the same; work has made everything so stressful." "Will things ever get better, he asks?"

PHYSICAL EXAMINATION: Examination reveals an alert, oriented (to time, place and person), overweight male. He appears anxious and somewhat restless. Vital signs are as follows. Blood Pressure 120/80 mmHg, Heart Rate 110/min - Supine; BP 90/60 mmHg; HR Thready - Standing (Patient complains of dizziness upon standing). Respiratory Rate - 20 /minute; Temperature 98 F.

 HE-ENT/SKIN: Facial pallor and cool, moist skin are noted. No telangiectasia of the lips or oral cavity are noted. No spider nevi are seen. The parotid glands appear full.

 CHEST: Lungs are clear to auscultation and percussion. The cardiac exam reveals regular rhythm with an S4. No murmur is appreciated. Peripheral pulses are present but are rapid and weak in all 4 extremities.

ABDOMEN/RECTUM: The abdomen reveals a rounded abdomen. Bowel sounds are hyperactive. There is moderate tenderness in the epigastrium. The liver is percussed to 13 cm; the edge feels firm. The spleen was not felt and no masses were appreciated; the exam was felt to be suboptimal secondary to the patient's obesity. Rectal examination revealed black, tarry stool. Some fissures noted around the anus.

There are no Dupuytren's contractions.

LABORATORY TESTS: Hemoglobin 9gm/dL, Hematocrit 27%, MCV 90. WBC 13,000/mm. PT/PTT - normal. BUN 45mg/dL, Creatinine 1.0 mg/dL. Chest x-ray - normal. X-ray of abdomen (kidney, ureter, bladder - KUB) is unremarkable.

Chose a priority from the case study

1. From your priority heading, Formulate a nursing diagnosis using 3 point diagnosis i.e. Issue, related to and evidence by
2. List a goal to support your diagnosis- ensure your goals is SMART
3. Identify, list/transfer the manifestations/data to support your diagnosis
4. Identify 4 interventions that would allow you to achieve your goal
5. identify 4 rationale that supports the intervention. Your rationale must be evidenced-based (literature supported)

STEP 1- NURSING DIAGNOSIS- identify 1 (one) priority nursing diagnosis

STEP 2- GOAL or OBJECTIVE-identify 1 (one) goal or objective that will address your nursing diagnosis

STEP 3 - COMPLETE THE PRIORITY MANIFESTATION, NURSING INTERVENTION WITH RATIONALE- for the most urgent Nursing Problem/diagnosis, identify 5 (five) appropriate and priority Nursing Interventions, with a rationale for each. Your rationale MUST be supported with literature and reference.

Step 1. NURSING DIAGNOSIS:

Step 2. GOAL/OBJECTIVE:

Step 3.