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Whats the 3 nursing diagnoses (NANDAs), 3 interventions for each diagnosis, and goals for each diagnosis. Use your nursing diagnosis book for proper diagnosis.

 

Case Study: Michael J.

 

This is Michael J, DOB 2/29/19XX, 44yr old Panamanian man. He was brought into the emergency department at 0900 with a known diagnosis of stage 3 pancreatic cancer. His main complaint is severe pain and nausea/vomiting, pt states “I am nauseous and have been vomiting for the last 5 hours and my pee is very yellow/orange”. He is very weak and frail, he has visible muscle atrophy and is a high fall risk. Confused, A&O x2 alert to self and location, not oriented to time or purpose.

 

On arrival, vital signs were : HR 113 BP 80/50 RR 28 O2 97% R, temp 103.2. He is responsive to pain, recoiling from noxious stimuli, pt states “pain is a 8/10” on the pain scale He has a 20G IV in his right AC. Has received 2L of the normal saline bolus, was given Morphine 4mg IV Q2hr PRN @0930, Phenergan suppository 25mg PR. Has urinated in urinal about 300mls of urine that was dark yellow and had a foul odor. UA was negative, however, it did show large blood cells in urine. 

 

He is allergic to Naproxen and Aspirin He has a history of newly diagnosed diabetes type 2 with the most recent blood glucose check at 190 mg/dL- he was given 3 units of regular insulin sub q at 0945, current chronic alcoholism, pancreatitis has a 49-year pack history, stage 3 pancreatic cancer, and jaundice.

 

 

An abdominal CT scan with contrast shows that there is possible metastasis to the liver, stomach, and bones. Chest x-ray shows several masses in the sternum and along the ribs, however, lung fields appear to be free from any mass. Lab values are as follows: WBC 1.02, Total Billirubin 3.2, Alkaline phosphatase 250, AST 104, ALT 79, PT 27. 

 

Provider orders: – Reverse isolation precautions – Tylenol 650mg PR q4hr alternating with Motrin 400mg PR q4 hr – Abdominal ultrasound for ascites measurement – Interventional radiology consult for paracentesis – CT scan for liver boarders – MRI for metastisis spread – Morphine 2mg IV q4hr PRN pain 4-6/10 – Dilaudid 1mg q2hr PRN pain 7-10/10 – Norco 5/325 q2hr prn breakthrough morphine pain 1-3/10

 

– Continuous cardiac monitoring – IV NS 75ml/hr – Phenergan 25mg PR q6hr nausea and vomiting – Call for Palliative care consult – POLST medication only code (in chart) – Questran 4gm per day first two doses, 8 gm per day following 6 doses, if itching continued, increase to 12gm per day for 5 days. – Narcan 2gm IV PRN respiratory rate below 6 – Oxygen up to 6L PRN o2 saturation below 90% NC or Simple Mask – 8,000 units Heparin IV STAT; 50units/kg of body weight Heparin q8hr – Lactulose 30ml PO TID – Ammonia blood draw STAT, BID AM and PM – MMSE evaluation q30min

SCIENCE
HEALTH SCIENCE
NURSING
NURS 120

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