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Nursing Care Plan AssignmentCase Study 2

Read this case study provided and answer the following questions from the case study provided. Also look at the potter and Perry text book fundamentals of nursing 6th edition and find your diagnosis.

1.Data Collection

2Data Clustering

3. Prioritizing

4.Date of admission:

5.Date of assessment:

6.Gender Identification:

7.Allergies:

8.Admitting Diagnosis

9.Past Medical History (diagnosis and date of diagnosis if possible)

10.Past Surgical history (diagnosis and date of diagnosis if possible)

11.Medication

12.Dose

13.Route

14.Frequency The Reason why this patient is taking this medication



Linda Shaw is a 56-year-old female who was brought to the hospital by EMS on December 23, 2019.  She presented to the emergency department with complaints of shortness of breath.  She has had a productive cough for 3 days with a fever.  She is admitted to the hospital with pneumonia and septicemia.  She has a history of cellulitis, iron deficiency, high cholesterol and hypertension.  She has an allergy to penicillin and vancomycin.  She is taking ramipril 10mg daily, atorvastatin 20 mg daily and iron replacement daily. Since her arrival to hospital she has been on IV ceftriaxone 1gm q24 hours.  She has been admitted for 2 days on the medicine unit that you are working on.  

Upon your assessment of the patient you notice she is short of breath during the interview.  She can get no more than two words out before having to stop talking and rest.  She is on wall oxygen at 2L via nasal prongs. You use your stethoscope to auscultate her chest and note decreased breath sounds to the LLL.  You are aware that she has a left-sided pneumonia.  You ask her to sit up in the bed and notice that she becomes increasingly short of breath with bed mobilization.  Her respiratory rate is 24/min with evidence of accessory muscle use (abdominal breathing).  You assess her oxygen saturation to be 92% on 2L of oxygen via nasal prongs.

When asked if she has any pain the patient states "I have a heavy feeling in my chest".  You ask her what makes this pain worse, Linda states "The pain is worse when I am coughing".  You ask Linda when she first noticed the pain, "I first noticed the pain at 5am today".  Linda mentions that the pain in her chest seems to move into her throat.  You ask Linda to describe the pain in her throat, "it is a scratchy pain".  Linda states that since changing her position on the bed she feels less pain.  Linda states "before you asked me to move up in the bed my pain was 7/10 but since moving it is now 2/10 and mostly gone from my throat".  

You assess Linda's heart rate to be elevated (99 beats/min).  You auscultate her apical pulse to match that finding.  You note that her pulse is regular.  You assess her blood pressure to be 111/80.   You compare that to the blood pressure that the previous nurse had obtained overnight.  Her pressure overnight was 118/79.  You recognize that her blood pressure is lower than normal and ask her if she is dizzy or lightheaded, she tells you that she is not.  

Linda is alert and oriented and answering questions appropriately with no evidence of confusion.  Upon assessment you note her pupils are equal and reactive bilaterally.  

Linda explains to you that she is feeling "unwell and tired".  She expresses frustration with her inability to sleep due to noise in the hallway at night.  She tells you that she overheard the nurses talking all night long about baking Christmas cookies and it made her sad because she may not be home for Christmas.

While Linda is talking to you about her inability to sleep, you notice that her oxygen saturation remains 92% despite her obvious shortness of breath when talking.  Also, while she is talking to you, you take a look at her skin tone and note a normal skin colour and normal skin temperature.  She does have dried blood at the site of her IV and the dressing is not intact.   You assess her temperature to be elevated at 39 degrees Celsius.  

Linda also expresses frustration to you about being constipated, "I think I need some bran flakes.  I haven't had a bowel movement in 2 days".  Her abdomen does appear distended. You palpate all four of her abdominal quadrants and note they are soft and appear to be non-tender.  You auscultate for bowel sounds and note that they are active in all quadrants.  You ask Linda if she is passing gas, "you betcha" she replies.  She tells you that before coming to the hospital she was 135lbs and that she believes she has lost weight.  You ask her why she thinks this, "I haven't eaten well since arriving to this hospital.  I have no appetite and it seems to take a lot of effort to eat".  

She seems to be moving her legs in bed frequently while you are interviewing her.  You ask Linda, "Do you have pain in your legs?".  Linda explains that she does not have pain but rather wants to keep moving them so that she doesn't "stiffen up".  Linda goes on to explain that she has had soreness and morning stiffness every morning for the last several years and her family doctor is investigating for arthritis. She denies requiring any mobility aids currently and denies any history of falls.

You notice that Linda has a foley catheter insitu. There is 400cc of straw colour urine in the foley collection bag. You ask her why she has a catheter in.  Linda states "the nurses put this catheter in while I was in the emergency department, they needed a urine specimen.  Truthfully, I would like it out so that I can try to pee on my own".

Before terminating the interview, you hand Linda her cosmetic bag that she requested.  She tears up and states, "I am not feeling much like putting make-up on. I fear that I will never get better.  I seem to be wasting away in this bed.  I am on my own with two kids in university so all that I can think about is who is going to work to pay for what they need.  I need to get out of here!".



 

 


 

 

 

 

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Also look at the potter and Perry text book fundamentals of nursing 6th edition and find your diagnosis.Data Collection 2Data Clustering 3....
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