lizmohammad
Case Study: Anita Jones is a 60 year old who lives alone. Her…
Case Study:
Anita Jones is a 60 year old who lives alone. Her husband died 3 years ago from prostate cancer. Anita is too tired to cook and she has joint pain that she states is “unbearable”. She states that some days she is so weak and tired she cannot get out of bed. She has lost 5 pounds in 2 months and has no appetite. On occasion she realized that she had been sitting in one position and just staring into space for prolonged periods. Her joints are sore and she is afraid to use them. She has a fear of the pain medication for her rheumatoid arthritis and refuses to take them as she believes that it is causing her to be forgetful. She is much more forgetful and is being investigated for Alzheimer’s disease. She is trying to ambulate more and forcing herself to eat small amount even when she doesn’t feel like eating, and she feels that “it doesn’t worth the effort”. She sleeps 6 hours per night and gets up frequently to go to the washroom. Her legs are edmeateous (swollen) and she has some bruising to her legs and back. She has no friends and she is not involved in any social activity. She has a 10 year history of hypertension and she sometimes feels very dizzy when she gets out of bed. She is steady on her feet and has no falls. She has blurred vision and wears glasses. Her admission diagnoses are Diabetes Mellitus Type 2 and Failure to Thrive.
History and Assessment
Anita 60 year-old female admitted to the hospital with medical diagnoses of Diabetes Mellitus Type 2 and Failure to Thrive (FTT). She also has hypothyroidism, rheumatoid arthritis(RA) and Depression (multimorbidity). Past surgical history: appendectomy in 1990; Hysterectomy in 1993; Lumpectomy 1991, MI in 1990
History of MRSA and VRE from previous admission.
Language: English and French
Braden Score is 10
Anita lives by herself in her own home and has no mortgage. Her symptoms are severe fatigue, frequent urinary output, guilt, poor memory and concentration
Weakness joint deformities and pain from the RA.
Previously a smoker x6 years but quit smoking over 25 years ago.
Height is 5 feet 3 inches. Weight 136 pounds.
Her hair looks dull on inspection and not combed.
Reddened areas to the coccyx but no open area to skin
Skin pale cool and dry to touch; her mucous membranes in her mouth are dry as well.
Capillary refill to nail beds is <2 seconds
Patient states she is very sensitive to the cold.
Medications: Ramipril 10mg PO QD, Levothyroxine 75mcg PO QD, Metformin 1000mg PO BID, Tylenol 100mg PO every 6hours PRN
Medication Allergic: penicillin; Sulpha
Food Allergy: Peanut
Breathing normal no use of accessory muscle, no nasal flaring, no cyanosis
Respiratory rate = 20 Spo2= 93% on room air
BP 140/70, P 77, Temp. 36.
Breath sounds normal no wheezing or crackles, no shortness of breath
Heart sounds are regular, Normal S1 and S2 sound, No jugular vein distention
Urine concentrated and foul smelling
Redness to coccyx but no open area
Patient states she has had no appetite for the last month
Bowel movements occur once every 3 days after she uses a laxative.
Abdomen is round and soft, non-tender with active bowel sounds in all four quadrants.
Chest X-Ray and CT March. 12
Blood work completed March 13th results:
WBC 7.5 Normal (4.5 to 11.0 × 109/L
Hemoglobin- 120 Normal 120 g/L to 160 g/L.
Platelet- 200 Normal (130-380 × 109/L)
Na-Sodium- 135 Normal 136-146 mmol/L
K+-Potassium- 3.5 Normal 3.5-5.1
Creatinine- 90 Normal 53 - 115 µmol/L
Glucose Fasting- 10 Normal 4.0 to 7.0 millimoles/L
Nursing Care Plan Part #2. (10%)
Nursing diagnosis/problem
1 Short term goal
4 nursing interventions with cited rationale
Evaluation
Nursing Problem: Select the priority problem.
Signs and symptoms: from your data collection that support the chosen problem.
Priority Nursing Problem:
Signs and symptoms
1.
2.
3.
4.
5.
Short Term Goal:
Nursing Interventions:
Identify four appropriate Nursing Interventions with cited rationale.
Nursing Intervention Research-Based Rationale
Evaluation: Because you cannot truly evaluate the outcomes it will be important to provide an explanation about what, when and how would you evaluate the nursing interventions.
