Question

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 Book 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

1.Nursing Diagnosis

Acute pain (in abdomen) related to solid mass in colon as evidenced by abdominal bloating,constipation, absent bowel sounds, constipation

Goal:to relieve abdominal pain

Assessment

• Subjective data
  • Verbalization of pain
  • Problmes in bowel movements, constipation
  • Malena
• Objective data
  • Firm abdomen
  • solid mass in abdomen
  • Abnormal vitals

Nursing intervention and rationale

• Assess the nature of pain (intensity, duration,frequency) to get the baseline data and plan for care
• Administer medications as per order (pain killer to reduce pain) ,antibiotics to treat infection, stool softners to relive constipation,atipyretics to relieve fever and thus aide in relieve discomfort and abdominal pain
• Provide the patient a soft bland diet for easy absorption and digestion

Evaluation

Thepatient shouldbe relieved of pain

2.Nursing diagnosis

Imbalanced electrolyte level related to metabolic changes as evidenced by decreased potassium level

Goal:To normal use the potassium level

Assessment

• Subjective data
  • Fatigue
  • Constipation
  • Feeling low
  • Constipation
• Objective data
  • Vitals
  • Tachycardia

Nursing intervention and rationale

• Monitor the patient's serum electrolytes, to get the baseline data and plan for care
• Assess signs and symptoms of hypokalemia and prevent complications
• Monitor vital sign hourly because patient may have irregular heart beat and sudden heart attack
• Administer potassium drip to normalize the level ,this will reduce bloating, abdominal pain,normal heart rate and blood pressure, weakness and constipation
• Monitor ECG,hypokalemia signs can be assessed easily and appropriate steps can be done
• Provide patinet a potassium rich diet ,to increase potassium level

Evaluation

The patient will exhibit normal potassium level ,reduced fatigue,weakness,constipation