Construct a Nursing care plan for this patient addressing 3 problems.(2actual+ 1 potential nursing diagnosis = 3). include short term and long term goals, interventions and evaluations
Case study 1
A 28 year –old Asian woman is referred by her general practitioner (GP) with persistant vomiting at 7 weeks gestation. She is in her second pregnancy having had a normal vaginal delivery 3 years ago . She is now vomiting up to 10 times in 24 hours and has not managed to tolerate any food for 3 days. She can only drink small amounts of water.
She saw her GP a week ago who prescribed prochlorperazine suppositories but these only help for a few. She feels very weak and is unable to care for her son now.
On direct questioning, she has upper abdominal pain that is constant, sharp and burning. She has not opened her bowels for 5 days. She is passing small amounts of dark urine infrequently but there is no dysuria or haematuria. There has been no vaginal bleeding.
There is no other medical or gynaecological history of note except that she suffered persistent vomiting in her pregnancy requiring two overnight admissions.
EXAMINATION
She is pyrexia. Lying blood pressure is 115/68mmHg and standing BP 98/55 mmHg. Heart rate is 96/min. The mucus membrane appear dry. Abdominal examination reveals tenderness in the epigastrium but no lower abdominal tenderness. The uterus is not palpable abdominally.
|
Blood Tests |
Patient Blood Values |
Normal range for pregnancy |
|
Haemoglobin |
11.1 |
11-14g/dl |
|
Mean Cell Volume |
90 |
74.4 – 95fL |
|
White Cell Count |
8.9x10 9/L |
6-16x 10 9/L |
|
Platelets |
298 |
150-400x10 9/L |
|
Sodium |
131 |
130-140mmol/L |
|
Potassium |
3.0 |
3.3-4.1mmol/l |
|
Urea |
8.2 |
2.4-4.3 mmol/L |
|
Creatinine |
65 |
34-82umol/L |
|
Alkanine transaminase |
30 |
6-32IU/L |
|
Alkaline phosphaytase |
276 |
30-300IU/L |
|
Bilirubin |
12 |
3-14umol/L |
|
Albumin |
34 |
28-37 g/L |
|
Pregnancy Test: Positive |
|
|
|
, |
|
|
Urinalysis. Blood- -ve, Nitrites-ve, leucocytes –ve,
Questions.
- Construct a Nursing care plan for this patient addressing 3 problems.(2actual+ 1 potential nursing diagnosis = 3). include short term and long term goals, interventions and evaluations
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