Case Study #5 William Borrows is a 23-year-old male of Chinese descent. He is a recent immigrant to the US, just recently moved here from China three months ago. William works in the IT industry and lives in a small studio apartment. He sends all of his extra money home so that he can help move his family here to the US one by one. His English is functional, but he is still uncomfortable speaking the language. He asked one of the ER nurses to please call his temple so that one of the Monks can come and visit him in hospital because he is afraid that he may have done something bad to someone and that is why he has gotten sick. William showed up at the ER three days ago complaining of right upper quadrant abdominal pain 6/10 that increased after meals. Williams last bowel movement was 2 days before he came into the ER. William decided to come to the ER after he started vomiting after eating. William was admitted to the hospital with a diagnosis of gallstones. William’s vital signs are: HR 99 BP 139/76 RR 22 O2 99 Temp 99.8 Pain 8/10 Williams labs were as follows: Labs: WBC 15 AST 80 ALT 97 Amylase 98 Lipase 250 Abdominal ultrasound: revealed gallstones HIDA scan revealed that there is a blockage in the gallbladder preventing clearance, solidifying dx of gallstones ERCP revealed that the ducts from the gallbladder are blocked. William has undergone a cholecystectomy without any complications. On waking William was complaining of pain 8/10 and Dilaudid was given. This brought William’s pain down to 2/10 which William reports as tolerable. While hospitalized the orders for William are as follows: Diet- high fiber Medications- Dilaudid 0.5mg IV q2h PRN pain greater than 5/10 Tylenol 650mg PO q6h PRN pain between 1-4/10 Zofran 4mg IV q6h PRN nausea Zosyn 3.75 gm q6h IV NS 75ml/hr IV continuous Ambulate after surgery Schedule GI follow up 1 week post discharge By 8 hours post surgery William had no bowel sounds and his abdomen was distended. William was stating his pain was 10/10. The surgeon was called to assess William and he was diagnosed with paralytic ileus and was admitted for another 3 days. Doctors orders were as follows: NG tube insertion, intermittent suction for 24 hours, remove after 24 hours NPO diet. Once NG tube is removed, slowly increase diet as tolerated. William has a medical history of asthma (ProAir MDI 90mcg 2puffs PRN q2h SOB), urinary retention post hypospadias correction as a child so he self-caths every 4 hours or as needed, right humoral fracture as a teenager with ORIF 1. 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. 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 #5
William Borrows is a 23-year-old male of Chinese descent. He is a recent immigrant to the US, just recently moved here from China three months ago. William works in the IT industry and lives in a small studio apartment. He sends all of his extra money home so that he can help move his family here to the US one by one. His English is functional, but he is still uncomfortable speaking the language. He asked one of the ER nurses to please call his temple so that one of the Monks can come and visit him in hospital because he is afraid that he may have done something bad to someone and that is why he has gotten sick.
William showed up at the ER three days ago complaining of right upper quadrant abdominal pain 6/10 that increased after meals. Williams last bowel movement was 2 days before he came into the ER. William decided to come to the ER after he started vomiting after eating. William was admitted to the hospital with a diagnosis of gallstones.
William’s vital signs are: HR 99 BP 139/76 RR 22 O2 99 Temp 99.8 Pain 8/10
Williams labs were as follows:
Labs: WBC 15 AST 80 ALT 97 Amylase 98 Lipase 250
Abdominal ultrasound: revealed gallstones
HIDA scan revealed that there is a blockage in the gallbladder preventing clearance, solidifying dx of gallstones
ERCP revealed that the ducts from the gallbladder are blocked.
William has undergone a cholecystectomy without any complications. On waking William was complaining of pain 8/10 and Dilaudid was given. This brought William’s pain down to 2/10 which William reports as tolerable.
While hospitalized the orders for William are as follows:
Diet- high fiber
Medications- Dilaudid 0.5mg IV q2h PRN pain greater than 5/10
Tylenol 650mg PO q6h PRN pain between 1-4/10
Zofran 4mg IV q6h PRN nausea
Zosyn 3.75 gm q6h IV
NS 75ml/hr IV continuous
Ambulate after surgery
Schedule GI follow up 1 week post discharge
By 8 hours post surgery William had no bowel sounds and his abdomen was distended. William was stating his pain was 10/10. The surgeon was called to assess William and he was diagnosed with paralytic ileus and was admitted for another 3 days.
Doctors orders were as follows:
NG tube insertion, intermittent suction for 24 hours, remove after 24 hours
NPO diet.
Once NG tube is removed, slowly increase diet as tolerated.
William has a medical history of asthma (ProAir MDI 90mcg 2puffs PRN q2h SOB), urinary retention post hypospadias correction as a child so he self-caths every 4 hours or as needed, right humoral fracture as a teenager with ORIF
1.
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.
- 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.)
4.
Implementation (Specific nursing interventions that were performed during your shift): Take Action
Must contain the following: Assess {observe, auscultate, palpate, percuss}; Monitor; Prepare, administer; Collaborate w/ specific multi-disciplinary team; & teach, i.e., VERBS
5. Evaluation (What was the outcome: Did you meet your desired goal?) Do your interventions address further monitoring of the patient’s response to your interventions and to the achievement of the desired outcome?
Goal; Met or Not met or partially met ?
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