unning head: CASE STUDY GRID

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Case Study Grid “Case History of Debbie”
Janet Ibrahim
NUR/403
September 21, 2015
Dr. Sherrily Mulleneaux

Case Study Grid “Case History of Debbie”

Five factors that demonstrate nursing needs:

1. Nutritional maintenance
2. Post-operative pain and nausea
3. Lacks knowledge about the importance of self-breast exams
4. Concerned about her and family’s future (2 daughters)
5. Emotional abuse from spouse

Nursing Diagnosis 1: Pain (Acute)

Rationale: Common among cancer patients. This is proved by various testimonies of Class V cervical cancer patients. Acute pain results from the activity of cancer cells and is related to the body’s surgical interruption.

Desired Outcome 1

Desired Outcome 2

Nursing Intervention 1

Assess the client for pain presence routinely.

Monitor the clients pain on a scale of 0-10 every shift or as needed.

Client will use a self-report tool to identify current pain intensity level and establish a comfort –function goal within a few hours after surgery.

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Client will be able to describe and use pharmacological and nonpharmacological methods that can be used to help to achieve their comfort- function goals prior to discharge.

Nursing Intervention 2

Provide rest periods to facilitate comfort, sleep, and relaxation

Pain level will decrease over the next 30 days.

As the patients pain level decreases, so will their fatigue over the course 4-6 weeks post operatively.

Evaluation method

Nursing Intervention 1- Patient will report satisfactory pain control at a level less than 3-4 using a pain scale of 0-10. Patient is able to use their pain pump (PCA) as needed if ordered, and uses other means of pain management such as relaxation techniques, distraction, imagery and application of cold and heat as pain lessens.

Nursing Intervention 2- Monitor the patient’s ability to perform tasks at their own pace; The patient’s will state exaggerated pain and exhaustion decreases with periods of rest.

Nursing Diagnosis 2: Imbalanced Nutrition: Less than body requirements

Rationale: Less than body requirements actual metabolic needs in excess of intact with weight loss R/T to increased caloric requirements and difficulty and absorbing sufficient calories secondary to cancer.

Desired Outcome 1

Desired Outcome 2

Nursing Intervention 1

Explain the need for increased consumption of carbohydrates, fats, proteins, vitamins, mineral and fluids. Dietitian consultation, monitor food intake.

The patient will progressively gain weight toward desired goal with in three to five days post operatively.

The patient will eat daily nutritional requirements in accordance with activity level and metabolic needs as soon as they are able to ambulate and take food post operatively.

Nursing Intervention 2

Ascertain the patient’s food preferences, provide the patient with high- protein high –calorie, nutritious finger foods and, drinks that can be readily consumed, as appropriate.

Patient will identify nutritional requirements and consume adequate nourishment within time of discharge from the hospital.

Recognize factors of contributing to underweight, be free of signs, which may have ongoing factors involved and may take 3-6 months more or less.

Evaluation method

Nursing Intervention 1 – Patients nutritional status indicator, by the amount of food and fluid intake/Body mass index/ Weight-height ratio/Hematocrit levels, having steady improvement in weight gain. Lab tests such as: serum albumin > than 3.5, prealbumin, serum total protein, serum ferritin, transferrin, H&H, and electrolyte levels stable daily.

Percentage of food intact gradually increases over a consistent period of three days.

Nursing Intervention 2 – Patient starts to Adapt and explores new types of nutritious foods to consume, and shows a willingness to do so. Physical signs of malnutrition resolving.

Patient begins to take small frequent meals of foods with increased calories and protein.

Patient shows consistent weight stability over the next 3-6 months during clinic visits.

Nursing Diagnosis 3: Fear related to possibility of early death due to stage V cervical cancer and the impact on her two daughters

Rationale:

Desired Outcome 1

Desired Outcome 2

Nursing Intervention 1

Evaluate how the client communicates with family in home environment.

Patient will state concerns about the impact of death on others by her next post op visit.

The client, Debbie will be able to go through the grieving process and find peace within herself.

Nursing Intervention 2

Assist client to find and participate in cancer support group.

Patient will seek help within the next two to three weeks in dealing with feelings and knowledge about her disease process.

Patient will become less fearful and be able to voice fears regarding prognosis openly with her family members

Evaluation method

Nursing Intervention 1- The patient expresses readiness for death by supporting family through the grief stage, resolves important issues with family members; discusses spiritual concerns and begins using prayer or other religious practices for comfort.

Nursing Intervention 2 - Patient begins to share feelings about dying with others facing similar situations as hers, during group meetings. Communicates willingness to discuss death with family members and friends.

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References

Ackley, B.J., & Ladwig, G.B. (2014). Nursing Diagnosis Handbook (10th ed.). Maryland Heights, Missouri: Mosby.
Breivik, H. et. al. (2008). Assessment of pain. Br J Anaesth, 101(1), 17-24.
Dwyer, J. (2011). Nutrient Requirements and dietary assessment. I (18th ed.). New York, New York: McGraw- Hill.
Halliday, L., & Boughton, M. (2008). The moderating effect of death experience on death anxiety. Implications for nursing education, 10(2), 76-82.





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