Case Study Health History (subjective data) • Darrell Kinsey is a 55-year old, male admitted to. Question
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Case Study Health History (subjective data)
• Darrell Kinsey is a 55-year old, male admitted to the hospital with an upper gastrointestinal bleed (UGIB). For this admission, he reported epigastric pain, melena, fatigue, dizziness, and mild shortness of breath with exertion for the past 2 days. His medical history includes arthritis of the right shoulder and hypercholesterolemia. He has an allergy to nuts which causes hives.
• In addition, he reports a previous hospitalization 4 months ago for UGIB in which he was newly diagnosed with a duodenal peptic ulcer, but was negative for Helicobacter pylori infection. He was treated with endoscopic injection therapy and a blood transfusion. He cannot recall his hemoglobin level or how many units of blood he was given at that time.
• His current medications are Nexium 20 mg/day and Lipitor 20 mg/day. He has discontinued any use of non-steroidal anti-inflammatory drugs (NSAID), alcohol, and caffeine.
Physical Assessment and Diagnostic Evaluation (objective data) Emergency department,
• Vital signs: Oral temperature 98.5°F; respiratory rate (RR) = 28 breaths/min, slightly labored; heart rate (HR) = sinus tachycardia (ST) at 118 beats/min; blood pressure (BP)= 98/54 mmHg; oxygen saturation = 89% on room air; pain = 4/10 (0-10 pain scale) in the epigastric area.
• Diagnostic results: Abnormal serum results were hemoglobin (HB) = 7.9 gm/dL and hematocrit (HCT) = 35%. Other serum blood counts, chemistry, and coagulation results were within normal ranges. Upper endoscopy revealed no active bleeding. Chest x-ray showed clear lungs.
• Treatment: The patient was placed on 2L of oxygen via nasal cannula, intravenous (IV) fluids were started, and indwelling urinary catheter placed with 250 cc of clear urine output.
Admission to the nursing floor,
• The patient was alert, oriented, and cooperative upon admission to the medical-surgical unit and a transfusion of 1 unit of packed red blood cells was started. Within 30 minutes of the transfusion; the patient called the nurse complaining of chills, dizziness, and nausea. He appeared anxious and restless.
• His immediate vital signs were: Oral temperature 102° F; RR = 32 breaths/min, labored; HR = ST at 136 beats/min; BP= 88/50 mmHg; oxygen saturation = 87% on 2L of oxygen via nasal cannula; pain = 8/10 in the epigastric area and extending to the lower back.
• Skin, mucous membranes: Oral mucosal membranes pale. Skin and sclera slightly jaundiced. Sanguineous fluid oozing from the IV access site and other venipuncture sites.
• Cardiopulmonary: Lung sounds diminished in both bases with fine crackles. S1 and S2 auscultated. Extremities cool with trace pedal edema, peripheral pulses 1+, capillary refill 2-3 seconds.
• Abdomen, musculoskeletal: Slight distention, soft, tender, hypoactive bowel sounds. Minimal dark reddish urine in collection bag. Musculoskeletal: There was full range of motion (ROM) and strength in extremities except right shoulder (limited ROM, strength 4/5).
• STAT diagnostic results: Abnormal serum results were HB = 6.8 gm/dL, HCT = 30%; potassium = 5.8 mEq/L, total bilirubin = 2.6 mg/dL, blood urea nitrogen = 34 mg/dL, creatinine = 2.0 mg/dL, direct Coombs test positive for antiglobulin; prothrombin time and partial thromboplastin times increased. Urinalysis positive for free hemoglobin. Chest x-ray positive for bibasilar pulmonary infiltrates.
Summer To answer questions 1-3, use the scenario above
1. Identify the likely disorder, the underlying pathophysiology (i.e., cellular and tissue changes), and relate the changes to abnormal findings to support your interpretation. (20 points) Hint: We are in the immune system !
2. Identify all NANDA nursing diagnoses labels (just the label!) that apply to this patient (e.g., impaired swallowing). Identify the priority (#1) nursing diagnosis label; and for the (#1) nursing diagnosis label, explain the nursing interventions to address the identified problem. Provide evidence-based rationale to explain the need and/or benefit of each intervention. For interventions, include what the nurse should “monitor/assess”, “do”, and “teach” to the client. (20 points)
3. Describe at least TWO medical therapies used to treat the disorder and explain their specific mechanism of action and intended impact at the cellular and/or tissue level. (15 points)
To answer questions 4-5, choose ONE disorder from this week’s reading
4. For the chosen disorder, identify the disorder and describe the impact on the population including incidence, prevalence, costs, morbidity, mortality, and/or other appropriate issues. Be sure to identify the disorder, the population associated with the data, and the year(s) of data. (15 points)
5. For the chosen disorder, locate recommendations in a nursing journal article or professional nursing organization. Provide a brief summary of the information and specific recommendations for nursing actions to improve care for patients. (15 points) Hint: To increase the likelihood of locating a nursing journal or organization, look for some form of the word “nurse” in the journal or organizational name!
Scholarly Writing: Use correct spelling, grammar, sentence structure, formatting, professional terms, title page, paraphrasing, citations, and references. Sources current (<5 years old) and professional (15 points) SCIENCE HEALTH SCIENCE NURSING NUR 3125
Case Study Health History (subjective data) • Darrell Kinsey is a 55-year old, male admitted to
