Question

#1. Case Study Millie Larson is an 80 year old widow being seen in the Emergency Room. She complains that she hasn’t been feeling well the past few days. Your RN assessment is as follows: Chief complaint—“decreased appetite, not sleeping well, fatigue, abdominal pain off and on, constipation.” Past medical History: Hypertension, Atrial Fibrillation (A-fib), osteoporosis, anemia, Past Surgical History: Appendectomy, C-section x 2 Home Medications: Aspirin 81 mg daily, Metoprolol 100 mg daily, Oxycodone 5 mg q 4 hrs PRN pain, daily vitamin Social History: Widowed less than 1 year. Retired School teacher and housewife. Has 1 daughter and 1 son. Has 3 grandchildren and is active in the church. Denies tobacco and alcohol use. Assessment findings— thin faced, ill looking, obese, elderly female, Vitals: T-102.7 (Temporal), P-125 irregularly -irregular, R-20, BP- 176/90 O2 Sat- 90% RA Pain: 7/10 to left abdomen. Sometimes hurts above the “belly button”. Described as dull achy. Lung Sounds with fine crackles to bilateral posterior bases. Denies SOB (shortness of breath), or cough. Bowel Sounds Hypoactive to upper quads and lower right quad, absent to left lower quad. Pt denies passing flatus. Abdomen is firm and round. Pt states, Stools have been somewhat soft-loose with some blood in them. Skin intact, no edema noted. All pulses present. Laboratory Results: WBC 18 Potassium (K+) 2.1 HGB 8.0 Stool sample + for blood Diagnostic Studies: CT with contrast of abdomen shows a solid mass in the descending colon measuring 8cm x 6cm EKG shows ST segment sagging, T wave depression, and U wave elevation. Millie Larsen will be admitted to the Acute Care Floor for hypokalemia with EKG changes and abdominal pain Write 2 complete Nursing Diagnosis for Millie Larson. Use an approved Nursing Diagnosis by NANDA. State the goal, nursing intervention and rationale. Remember: Nursing intervention is how you will help your patient to achieve their goal while the Rationale should explain why you’re doing the nursing intervention. Nursing Diagnosis #1: Patient goal: List 2 Priority Nursing interventions related to the above Nursing Diagnosis. Provide Rationale for each intervention. Nursing Intervention 1: Rationale: Nursing Intervention 2: Rationale: Nursing Diagnosis #2: Patient goal: List 2 Priority Nursing interventions related to the above Nursing Diagnosis. Provide Rationale for each intervention. Nursing Intervention 1: Rationale: Nursing Intervention 2: Rationale:

Answer 1

ANSWER :

1. NURSING DIAGNOSIS FOR LOSS OF APPETITE :

NURSING DIAGNOSIS - Imbalanced nutrition less than body requirements related to loss of appetite as evidenced by aging

GOAL - To improve the weight pattern

NURSING INTERVENTIONS -

1. Provide diets which are high in nutrients and liked by patient

2. Educate patient to chew food particles,swallow and taste the food

RATIONALE -

1. To provide balanced diet

2. To maintain normal ingestion and digestion of nutrients

2. NURSING DIAGNOSIS FOR SLEEP DISTURBANCES

NURSING DIAGNOSIS - Disturbed sleep pattern related to abdominal pain as evidenced by restlessness

GOAL - To provide normal amount of sleep to patient

NURSING INTERVENTIONS -

1. Assess for sleep pattern of patient

2. Provide calm and quiet environment to induce normal sleep

RATIONALE -

1. To correct the causes that are causing disturbances in sleep

2. To stimulate normal sleep and avoid early awakenings