Case Study #4 Romina Jackobs is a 45-year-old morbidly obese French woman who moved to the US one year ago for a job promotion. She lives alone with her two cats. She says that she has made a lot of friends in the apartment building that she lives in, and her neighbor has called her and let her know that she will take care of her cats. Because she has only been in her new position for a year, she is worried that she will get into trouble if she has to miss too many days. As a regional public relations manager for Delta airlines, she has to travel a lot, she is worried she will miss a lot of her reports. She presented in the ER this morning complaining about pain in her right calf. On assessment her calf was red, edematous and hot to the touch. There was a palpable mass in the calf, so Romina was sent to ultra sound. Ultra sound revealed that there was an encapsulated mass in the calf, and pt was sent to CT scan. CT revealed that there was a large abscess in Romina's calf. The admitting doctor has put in orders for admission with a diagnosis of Abscess, a consult for surgery, wound care nurse evaluation post surgery, home health care consult on discharge, social worker consult, wound culture. The doctor has also ordered a transesophogeal Echocardiogram. Lab values were: WBC 17, 000 RBC 4.5 Hbg 13 HCT 35 Vital signs were: HR 115 BP 165/98 RR 24 Temp 102.3 O2 98 Pain 8/10 In the ER she was given morphine 2mg IV for pain that managed her pain well, however, she got very nauseous after the morphine. She is allergic to Zofran so the ER doctor ordered 12.5mg Phenergan for nausea. Romina has a medical history of : Chronic Heart Failure- Lasix 40mg qd in am Hypertension- Metoprolol 25mg BID Diabetes Type 2- Humalog sliding scale insulin qhs, ac BS 100-200 4 units BS 200-250 6 units BS 251-300 8 units BS 301-350 10 units BS 351+ 12 units Asthma- ProAir rescue inhaler 2inh PRN q 2 hrs GERD Pepcid 20mg BID Chronic Anemia- Ferrous sulfate 1000mg/day qd The doctor has ordered Vancomycin 1gm q8hrs IV, Zosyn 3.75gm q6hr IV and Ancef 1gm 30min pre-surgery. Because her anxiety has caused her asthma to become relentless, the doctor has also ordered solumedrol 40mg IV q8hr in an attempt to keep inflammation down systemically and relieve her asthma symptoms. Morphine 2mg IV q4hr for pain, Phenergan 12.5mg IV q 12hr for nausea. On entering Romina's room, there is a cane leaning against the wall across the room from Romina's bed and Romina appears frustrated. Romina reports that she has been needing to use the restroom, but can't get to her cane, so she can't get up out of bed without it. Your assessment shows that she has fine crackles in her lower lungs and has edema 2+ in BLE. Romina has her bed almost flat, and she is complaining of difficulty breathing. She states that her mattress is uncomfortable and she says she can feel the metal frame through it, and it's hurting her tailbone and her legs, she says that she is having a hard time shifting and trying to get comfortable, because every time she sits the bed up, she slides down. She said it feels like there are rug burns on her back from the constant sliding up and down in the bed. Heart sounds are muffled and a pericardial rub is heard. Bowel sounds are present in all 4 quadrants. Pt reports last BM was this morning and was within normal limits. No complaints of burning on urination. 1. ABNORMAL ASSESSMENT FINDINGS: Recognize Cues Assessment: What are the identified abnormal findings: List S&S= (Signs and symptoms, i.e., Abnormal Subjective and Objective Assessment Findings/lab results, etc.) 2. Analysis/Hypothesis: What is the cause of the patients problem that must be prioritized at this time? Evaluate the Hypothesis = (Signs and symptoms, i.e., Abnormal Subjective and Objective Assessment Findings/lab results, etc 3. Planning (Patient goals focus on resolving the problem), Must be SMART goals Generate Solutions Develops a list of actions to address the priority hypothesis. The student nurse then selects the appropriate action from the list and carries out the action. will (verbalize, demonstrate, be able to, increase & maintain, or decrease & maintain) by the: (end of shift, end of day, discharge day) or within: (two hours; 12 hours, etc.)
Case Study #4
Romina Jackobs is a 45-year-old morbidly obese French woman who moved to the
US one year ago for a job promotion. She lives alone with her two cats. She says that
she has made a lot of friends in the apartment building that she lives in, and her
neighbor has called her and let her know that she will take care of her cats. Because
she has only been in her new position for a year, she is worried that she will get into
trouble if she has to miss too many days. As a regional public relations manager for
Delta airlines, she has to travel a lot, she is worried she will miss a lot of her reports.
She presented in the ER this morning complaining about pain in her right calf. On
assessment her calf was red, edematous and hot to the touch. There was a palpable
mass in the calf, so Romina was sent to ultra sound. Ultra sound revealed that there
was an encapsulated mass in the calf, and pt was sent to CT scan. CT revealed that
there was a large abscess in Romina's calf.
The admitting doctor has put in orders for admission with a diagnosis of Abscess, a
consult for surgery, wound care nurse evaluation post surgery, home health care
consult on discharge, social worker consult, wound culture. The doctor has also ordered a transesophogeal Echocardiogram.
Lab values were:
WBC 17, 000
RBC 4.5
Hbg 13
HCT 35
Vital signs were:
HR 115
BP 165/98
RR 24
Temp 102.3
O2 98
Pain 8/10
In the ER she was given morphine 2mg IV for pain that managed her pain well,
however, she got very nauseous after the morphine. She is allergic to Zofran so the ER doctor ordered 12.5mg Phenergan for nausea.
Romina has a medical history of :
Chronic Heart Failure- Lasix 40mg qd in am
Hypertension- Metoprolol 25mg BID
Diabetes Type 2- Humalog sliding scale insulin qhs, ac
BS 100-200 4 units
BS 200-250 6 units
BS 251-300 8 units
BS 301-350 10 units
BS 351+ 12 units
Asthma- ProAir rescue inhaler 2inh PRN q 2 hrs
GERD Pepcid 20mg BID
Chronic Anemia- Ferrous sulfate 1000mg/day qd
The doctor has ordered Vancomycin 1gm q8hrs IV, Zosyn 3.75gm q6hr IV and Ancef
1gm 30min pre-surgery. Because her anxiety has caused her asthma to become
relentless, the doctor has also ordered solumedrol 40mg IV q8hr in an attempt to keep
inflammation down systemically and relieve her asthma symptoms. Morphine 2mg IV
q4hr for pain, Phenergan 12.5mg IV q 12hr for nausea.
On entering Romina's room, there is a cane leaning against the wall across the room
from Romina's bed and Romina appears frustrated. Romina reports that she has been
needing to use the restroom, but can't get to her cane, so she can't get up out of bed
without it. Your assessment shows that she has fine crackles in her lower lungs and
has edema 2+ in BLE. Romina has her bed almost flat, and she is complaining of
difficulty breathing. She states that her mattress is uncomfortable and she says she can
feel the metal frame through it, and it's hurting her tailbone and her legs, she says that she is having a hard time shifting and trying to get comfortable, because every time
she sits the bed up, she slides down. She said it feels like there are rug burns on her
back from the constant sliding up and down in the bed.
Heart sounds are muffled and a pericardial rub is heard. Bowel sounds are present in
all 4 quadrants. Pt reports last BM was this morning and was within normal limits. No
complaints of burning on urination.
1. ABNORMAL ASSESSMENT FINDINGS: Recognize Cues
Assessment: What are the identified abnormal findings:
- List S&S= (Signs and symptoms, i.e., Abnormal Subjective and Objective Assessment Findings/lab results, etc.)
2.
Analysis/Hypothesis: What is the cause of the patients problem that must be prioritized at this time?
- Evaluate the Hypothesis = (Signs and symptoms, i.e., Abnormal Subjective and Objective Assessment Findings/lab results, etc
3. Planning (Patient goals focus on resolving the problem), Must be SMART goals Generate Solutions
Develops a list of actions to address the priority hypothesis. The student nurse then selects the appropriate action from the list and carries out the action.
- will (verbalize, demonstrate, be able to, increase & maintain, or decrease & maintain)
- by the: (end of shift, end of day, discharge day) or within: (two hours; 12 hours, etc.)
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