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5 Nursing Diagnosis based on this case study Diagnosis related to…
5 Nursing Diagnosis based on this case study
Diagnosis
related to
evidenced by
Susan Patterson is a 30-year-old patient who is being admitted into the hospital for observation. She
has complaints of dyspnea (shortness of breath), a productive cough, and pain along with erythema
(redness) and tenderness in her right lower leg. She states that she has not been able to sleep very
well because of all of the coughing and shortness of breath. She has to try and sleep sitting up. Susan
has a history of smoking illegal substances (marijuana) and smoking three packs of cigarettes a day;
she is currently using estrogen for irregular menstrual cycles and now smokes one pack of cigarettes a day. Susan states that her boyfriend just left her, and she hasn’t been dealing with it very well. “I
guess I should be taking better care of myself.” “Smoking helps me relax.” Her BP is 128/88,
respiratory rate is 28, pulse 122, oxygen saturation of 89% on room air, and temperature of 99.5
degrees Fahrenheit. In the ER, blood work is drawn, and she is sent to get a CT scan and a VQ scan.
Results of her D-dimer were 4 mcg/mL and her V/Q scan showed that she had a 75% chance of having
a pulmonary embolism. “What is a pulmonary embolism?” “Am I going to die?” The ER nurse tries to
calm Susan by explaining her diagnosis. She asks Susan if there is someone to call for her to give her support. She states that her parents are elderly, and she does not want to bother them. “No, there is no one else.” When she gets up to her unit, the nurse performs a head-to-toe physical exam. Susan is alert and oriented x4. Her pupils are PERRLA and are both at 3mm. Eyes, ears, and nose are without
drainage. Face is without droop or lesions. No carotid bruits are auscultated on either side of her
neck. No prominent lymph nodes are felt. Thyroid is without enlargement or nodules. Chest
expansion is symmetrical. Patient seems as though she is using her accessory muscles to breath.
Upon auscultation, she has bi-basilar crackles posteriorly. She is visibly tachypneic. 2 liters of oxygen
was applied per order and brought her up to a pulse ox of 94%. Respiratory rate now at 22. She was
put on telemetry per doctor’s order. Telemetry showed sinus tachycardia at a rate of 120. Heart rate
was regular. S1, S2 were heard. S3 was noted when listening to the pulmonic site. BP was rechecked
and was 126/84. Overall skin appears diaphoretic and dusky in color. 2-inch white scar noted on left
knee. No other openings or lesions noticed anywhere else on skin. Right lower leg appears swollen
with +2 edema, bright red in color, painful to touch anterior and posterior. Patient able to perform active
ROM without much difficulty in all 4 extremities. No joint deformities seen. Abdomen flat without
complaints of pain on palpation. Patient states that her last BM was yesterday. No abdominal
pulsations visualized. Bowel sounds active in all 4 quads. Patient states that she is on an unrestricted
diet but usually tries to eat a lot of green leafy vegetables. She states that she has no nausea or
vomiting. States that her appetite has been good lately and that she usually eats 100% of her meals.
When asked about urination, she states that she hasn’t been able to urinate since 8 am. She states
that her urine was concentrated looking, a small amount, and foul smelling. She does not complain of
frequency but does complain of some discomfort when she urinates that she rates as a 4/10 on a 1-10
scale. When checking pulses, bilateral radial pulses were +2, right pedal pulse +1, left pedal pulse +2,
right posterior tibial pulse +1, left posterior tibial pulse +2, right femoral pulse +1, and left femoral
pulse +2. No other edema seen anywhere else other than the right lower leg. Gait steady. Sensation
intact when tested with a cotton ball on face, arms, abdomen, and leg. Biceps DTR symmetrical at +2,
and patellar DTR also symmetrical at a +2. Romberg test negative. IV lock started in left hand #20
with brisk blood return. Patient tolerated well. Temperature rechecked and now at 99.8 degrees
Fahrenheit. Orders received to start a heparin gtt at 10,000 units/mL and to give a heparin bolus of
5000 units IVP. Follow heparin gtt. Protocol for when to draw aPTTs. Patient’s weight is obtained at
135 lbs. She is ordered to have O2 at 2 liters to keep her pulse ox >90%. There is an order to bladder
scan the patient and to obtain a urine sample for culture and sensitivity. If the patient has greater
than 500 mL in the bladder, insert a catheter and consult urology. Lasix 20 mg IV x1 now is ordered.
Lopressor 5 mg IV q 6 hours prn HR>120. Ambien 10 mg po q hs prn sleep. Smoking cessation
education. Regular diet. Up as tolerated. Telemetry
