Answered step-by-stepJustine Walsh is a 45-year-old female d
Answered step-by-stepJustine Walsh is a 45-year-old female diagnosed with Crohn’s…Justine Walsh is a 45-year-old female diagnosed with Crohn’s Disease. Patient admitted through the Emergency Department with abdominal pain and hematochezia for 2 weeks. S/p hemicolectomy with a colostomy. Transferred to the medical/surgical unit for continued care and education. PMH of Crohn’s Disease, anxiety disorder and major depressive disorder. Personal/Social History: Married with two young children. She had stopped smoking (1/2PPD for 10 year) when her children were born but restarted during her worry of as her health status has deteriorate over the last several months. She smokes about 4 packs of cigarettes a month. She drinks 1 glass of red wine about twice a weekday. She does not regularly exercise.Mrs. Walsh has a younger sister aged 35 years who diagnosed with Crohn’s disease in her late 20’s. Her mother suffered from depression and is diagnosed with generalized anxiety disorder as well. Her father is healthy and is diagnosed with type 2 diabetes that is manage with diet and exercise. RELEVANT Data from Present Problem: Clinical Significance: RELEVANT Data from Social History: Clinical Significance: PMH: Home Meds: Pharm. Classification: Expected Outcome: Pantoprazole (Protonix) Lorazepam (Ativan) Citalopram (Celexa) 1. 2. 3. 1. 2. 3. Current VS: WILDA Pain Assessment (5th VS):T: (oral) 99oF Words: soreP: (regular) 88 Intensity: 4/10R: (regular) 20 Location: At incision siteBP:142/88 Duration: surgeryO2 sat: 99% on RA Aggravate:Alleviate: Nothingmedication What VS data is RELEVANT that must be recognized as clinically significant to the nurse?RELEVANT VS Data: Clinical Significance: Current Assessment:GENERAL APPEARANCE: Resting in bed, appears in no acute distressRESP: Nonlabored respiratory effort. Diminished breathe sounds bilateral LL.CARDIAC: Pink, warm & dry, no edema, heart sounds regular with no abnormal beats, pulses strong, equal with palpation at radial/pedal/post-tibial landmarksNEURO: Alert & oriented to person, place, time, and situation (x4)GI: Abdomen soft, no bowel sounds audible per auscultation in all four quadrants. Abdomen tender to touch. Colostomy stoma beefy red. Abdominal incision DSD intact, no drainage noted. GU: Foley Catheter draining urine clear/yellowSKIN: Abdominal incision, 14 staples, DSD C/D/I. Colostomy stoma protruding and beefy red. What assessment data is RELEVANT that must be recognized as clinically significant to the nurse?RELEVANT Assessment Data: Clinical Significance: Nursing Interventions: Rationale: Expected Outcome: Clinical Reasoning Begins…1. What is the primary problem that your patient is most likely presenting with? What is the underlying cause/pathophysiology of this concern? 3. What nursing priority(s) captures the “essence” of your patient’s current status and will guide your plan of care? (if more than one-list in order of PRIORITY) Medical Management: Rationale for Treatment & Expected OutcomesCare Provider Orders: Rationale: Expected Outcome:OOB to chair x30 min. BID NPO NGT to low continuous suction Accu check q6hr Foley catheter Strict I&O DSD dressing change daily and prn to keep dry Assess stoma qshift PICC line care PRIORITY Setting: Which Orders Do You Implement First and Why?Order of Priority: Rationale: Lab Results:What lab results are RELEVANT that must be recognized as clinically significant to the nurse?Complete Blood Count (CBC:) Current: High/Low/WNL?WBC (4.5-11.0 mm 3) 11.8 Hgb (12-16 g/dL) 12 Platelets (150-450 x103/µl) 245 Neutrophil % (42-72) 43 Band forms (3-5%) 4 What lab results are RELEVANT that must be recognized as clinically significant to the nurse? RELEVANT Lab(s): Clinical Significance: Basic Metabolic Panel (BMP:) Current: High/Low/WNL?Sodium (135-145 mEq/L) 136 Potassium (3.5-5.0 mEq/L) 3.6 Chloride (95-105 mEq/L) 96 Glucose (70-110 mg/dL) 106 Calcium (8.4-10.2 mg/dL) 8.5 BUN (7-25 mg/dl) 9 Creatinine (0.6-1.2 mg/dL) 0.8 RELEVANT Lab(s): Clinical Significance: Twenty-four hours later:Patient complained of increase pain to entire abdomen rate 8/10. Patient was medicated with prn morphine sulfate for pain with no effect. An abdominal X: Ray and CT scan was ordered that indicates an anastomotic leak. The patient needs to be prep for surgery and the doctor order repeat labs, stat cbc, bmp and lactate acid as see below. The RN reassessed the patient vital signs and they are as follow. Current VS: WILDA Pain Assessment (5th VS):T: (oral) 101.4F Words: soreP: (regular) 112 Intensity: 10/10R: (regular) 24 Location: Entire abdomen BP: 98/60 Duration: surgeryO2 sat: 92% on RA Aggravate:Alleviate: Nothingmedication Lab Results: What lab results are RELEVANT that must be recognized as clinically significant to the nurse? Complete Blood Count (CBC:) Current: High/Low/WNL? Most Recent:WBC (4.5-11.0 mm 3) 14.5 Hgb (12-16 g/dL) 11 Hct (35-47 g/gL) 22 Platelets (150-450 x103/µl) 325 Neutrophil % (42-72) 75% Band forms (3-5%) 5% What lab results are RELEVANT that must be recognized as clinically significant to the nurse? RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Stable: Basic Metabolic Panel (BMP:) Current: High/Low/WNL? Most Recent:Sodium (135-145 mEq/L) 138 Potassium (3.5-5.0 mEq/L) 3.8 Chloride (95-105 mEq/L) 100 CO2 (Bicarb) (21-31 mmol/L) 22 Anion Gap (AG) (7-16 mEq/l) 10 Glucose (70-110 mg/dL) 78 Calcium (8.4-10.2 mg/dL) 9.5 BUN (7-25 mg/dl) 22 Creatinine (0.6-1.2 mg/dL) 1.0 RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Stable: RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Stable: What body system(s) will you most thoroughly assess based on the primary problem or nursing care priority? What is the worst possible/most likely complication to anticipate based on the primary problem? What nursing assessments will identify this complication EARLY if it develops? What nursing interventions will you initiate if this complication develops? Health ScienceScienceNursingNURSING 2005Share
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