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Nursing Case Study: Assessments, Lab Tests, and Diagnostic Studies

Added on -2019-09-16

This nursing case study discusses the assessments, lab tests, and diagnostic studies needed for a 70-year-old African American female with multiple medical conditions. The patient's primary medical diagnoses, medications, and vital signs are analyzed, and a nursing care plan is created.
| 3 pages
| 992 words

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Nursing 300Case StudyFall 2016MK is a 70-year-old African American female, who is brought to the hospital at 1 pm by her daughter after experiencing and episode of dizziness and confusion that lasting20 minutes at 9 am. MK, a widow and retired school nurse, lives on the first floor of a two family home with her daughter’s family occupying the 2nd floor of the home. She currently has a home health aide 4 hours a day to assist with ADLs and household chores following surgical removal of 2 of her lesser toes on her left foot 3 months ago which hasaffected her mobility. She is able to move about her home short distances with the assistance of a walker but uses a wheel chair outside the home. She receives dialysis 3 days a week at an outpatient center. Her daughter describes her as an independent womanwho has over the last 6 months begun to be forgetful with periods of confusion.MK has a history of asthma, hypertension, type II diabetes, chronic renal failure, and breast cancer treated with surgery and chemotherapy. She is a former smoker from ages 20-40. In addition to the surgical amputation she has a surgical history of cesarean section, left breast modified radical mastectomy 4 years ago with radiation. She has not received chemotherapy. She has a left arm AV fistula for dialysis which is patent. She is 5 feet 1 inch tall and weighs 176 lbs. She is currently taking the following medications:Nephrovite 1 tablet PO dailyHydrochlorothiazide (HCTZ) 50 mg PO twice dailyEnalapril (Vasotec) 10 mg PO dailyFluticasone/vilanterol (Breo) 100mcg/25mcg Dry powder inhaler 1 puff dailyHumulin insulin 70/30 12 units @ 8am acHumulin insulin 70/30 4 units @ qhsAdvair 100 mcg inhaled twice dailyRegular insulin sliding scale:2 units for blood glucose of 200-2504 units for blood glucose of 250-3006 units for blood glucose of 300-350> 350 call md.

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