Question

Please provide nursing diagnoses for the following:

Cardiovascular: RRR (regular rate and rhythm), prominent heart sounds, S1 and S2 normal, pulses 2+ symmetrically, no m/g/r (murmurs, gallops, rubs), mild SOB, no chest pain, edema or DOB (difficulty of breathing).

Respiratory: Good air movement, no crackles/rhonchi/wheezes, diffusely decreased breath sounds bilateral.

GI: Normoactive bowel sounds, no rebound or guarding, abdomen muscular and tense, NT (non-tender), ND (non-distended), liver palpable 1-2 cm below costal margin, difficult to palpate spleen due to rigidity of abdomen. No presence of N/V/C/D (nausea, vomiting, diarrhea, constipation), BRBPR (bright red blood per rectum), GER (gastroesophageal reflux), abdominal pain or bowel changes.

Answer 1

• The possible diagnosis in this case is she might be obese with hepatomegaly or fatty liver.
• second possible diagnosis is bilateral pleural effusions.(less likely because in pleural effusion there will be focal or absent breath sounds). whereas, diffuse decreased breath sounds are usually noticed in obese patients due to thick chest wall or obstructive lung disease which is less likely in this case .
• usually spleen is not palpable in normal individuals.abdominal rigidity is often associated with pain but she has no pain so possibility of peritonitis or gall stone disease are not possible.