Mona Dryfus is a 58 year old moderately obese woman with a history of osteoarthr

Question

Mona Dryfus is a 58 year old moderately obese woman with a history of osteoarthritis, alcohol abuse, 15 pack year smoking, and diverticulosis. She was admitted yesterday to the medical surgical floor with stomach pains. Radiology of the abdomen reveals diverticulitis and hepatomegaly. Admission assessment information is as follows:

Height and weight: 62 in. 258 lbs.

Vital signs: Temperature: 100.2, Pulse: 98, Respirations: 26, Blood pressure: 111/68, Pulse oximetry 94%, Pain 6/10

General survey: Moderately obese female with generally unkempt appearance. Patient appears in distress, complains of pain in abdomen and slight nausea. Pain is dull and aching. States has not moved bowels for 48 hours, not eaten much in same time.

Neurological: No neurological deficits noted. Patient is appropriate, alert, and oriented x 4

Cardiac: S1, S2 auscultated, pulses +2

Respiratory: Scattered rhonchi, decreased to bases, productive cough, minimal yellowish sputum

GI: Abdomen is tense, tender to palpation, distended. Bowel sounds positive x 4. States last bowel movement was 48 hours ago.

GU: Patient states no difficulty voiding urine, denies pain, urgency, or frequency

Musculoskeletal: Patient states osteoarthritis in knees "pretty bad." She states she mostly stays in her recliner because walking and standing hurt.

Integumentary: Patient has thin dry skin, breakdown in abdominal folds, dry mucus membranes.

After reading the case study, please answer the following questions:

List three priority nursing diagnoses and the associated assessments and interventions.

List two risk for diagnoses and interventions

Discuss the lab results. Which ones are abnormal? Which ones should be called to the health care provider? What could be possible causes of these abnormalities?

Explanation / Answer

Nursing diagnosis

1 altered comfort due to pain

- provide analgesics as order, provide comfortable position, provide non pharmaceutical meseurs

2- hyperthermia

- administrator antipyretic, provide cold sponge bath, make room cool, encourage to take bath

3-ineffictive breathing patterns

- administrator bronchodilator as order, provide oxygen, provide chest physiotherapy

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