Nursing 300 Case Study Fall 2016

This document presents a comprehensive case study of a 70-year-old African American female patient, MK, admitted to the hospital with near syncope and mental status changes. The assignment requires a detailed analysis of the patient's medical history, current medications, and vital signs. It inclu...Read More

Nursing 300
Case Study
Fall 2016
MK 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 lasting
20 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 has
affected 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 woman
who 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 daily
Hydrochlorothiazide (HCTZ) 50 mg PO twice daily
Enalapril (Vasotec) 10 mg PO daily
Fluticasone/vilanterol (Breo) 100mcg/25mcg Dry powder inhaler 1 puff daily
Humulin insulin 70/30 12 units @ 8am ac
Humulin insulin 70/30 4 units @ qhs
Advair 100 mcg inhaled twice daily
Regular insulin sliding scale:
2 units for blood glucose of 200-250
4 units for blood glucose of 250-300
6 units for blood glucose of 300-350
> 350 call md.

MK’s vital signs are B/P 172/94, Pulse 96, Resp. Rate 22, oral temperature of
37.8, and oxygen saturation is 91% on room air. She has a dry non-productive cough and
with lung sounds clear to auscultation. She has bilateral lower extremity +2 non-pitting
edema. She has urine output of 200/ml over the last 24 hours. She has capillary refill of
2 seconds. Her skin is warm and dry She is alert and oriented to person and place but is
unable to name the hospital, remember how she arrived at the hospital or the date/time.
She is cooperative and responds to questions with clear speech. These mental status
changes are changes from her base line of alert oriented to person, place and time. She is
admitted to the hospital with a diagnosis of near syncope and mental status changes.
Assignment
Please briefly answer the questions in your own words using your text(s) as your
resource. Describe the assessments you would conduct. Please list the appropriate lab
tests and possible other diagnostic studies you anticipate will be needed to understand
your patient’s current problems. Describe what information/results of the labs or studies
would mean.
This activity will get you to think critically about the “whole” picture instead of
just one problem or just one lab. This paper should be 4-5 pages long excluding
references or cover page. The paper should be in APA format with cover page and your
name in both the header and file name of the paper. There should be no errors in grammar
or spelling. You will submit your paper via “Turnitin by the assigned date of January 1st.
Sections 1-5 are worth 5 points each
1. How do the patient’s age, gender and ethnicity affect risk factors for the
presenting problem for this patient?
2. What are the modifiable risk factors for this patient?
3. What is/are this patient’s primary medical diagnosis(es) and what do they mean in
terms of nursing care?
4. How does the patient’s current presentation/physical findings confirm the
admitting diagnosis? What studies are needed to fully evaluate this patient (labs or
diagnostic tests)
5. Identify any vital signs that are out of normal range (high or low) and list the
normal ranges based on this patient’s age and/or sex. Discuss the relation of the
abnormal vitals to the primary diagnosis. Is this consistent with or expected of a
patient with this diagnosis?
Section 6 is worth 20 points
6. Discuss each of the patient’s medications. Include the dose, route and frequency.
For each medication listed discuss the following:
a. Why this medication is prescribed?

b. How does this medication mediate or treat the patient’s condition?
c. What are the major side effects or precautions for the medication for this
patient (consider patient’s demographics, diagnosis and any medication
interactions)
d. List any lab studies needed with these medications.
Sections 7 is worth 20 points
7. What educational plan would you create for this patient? How would you include
the patient’s family member in this plan?
Section 9 is worth 30 points
8. Based on the information you have gathered about this patient, create a nursing
care plan for the patient including a plan for patient education. Include and
describe the use of and rationale for:
a. Priority Nursing Diagnoses
b. Patient Centered Goals
c. Interventions for each Goal
d. Evaluations
Grammar, spelling and style are worth 5 pts