Question

IM DOING A CASE STUDY AND NEED THE FOLLOWING BELOW

1.NURSING DIAGNOSIS

2.SUBJECTIVE DATA

3.IMPLEMENTATION

4.RATIONALE

5.EVALUATION

6.OBJECTIVE DATA

7.EXPECTED OUTCOMES

Cholecystitis Case Study

Mr. S. is a retired 54-year-old male who arrives at the emergency room (ER) by ambulance. Mr.

S. and his girlfriend were out celebrating by eating a steak-and-lobster dinner at their favorite

restaurant. While eating dessert, Mr. S. had grabbed his chest and stated, “It feels like an

elephant is stepping on me.”

On the way to the ER, Mr. S. had vomited 400 mL of liquid emesis mixed with undigested food.

The paramedic had started an 18-gauge intravenous (IV) site in his left antecubital fossa and 2 L

of oxygen via nasal cannula. His girlfriend states, “He has had this kind of pain before, but it

would always go away. I could never convince him to tell his doctor, but it’s never been this bad

before.... It’s his heart, isn’t it?”

Mr. S.’s vital signs are • B/P 186/94 • Apical pulse 110 bpm and irregularly irregular •

Respirations 26–30 and shallow

He is 69 inches tall, weighs 115 kg, and has a history of hypertension, type 2 diabetes mellitus,

and occasional sinusitis from seasonal allergies. He tells the ER nurse he took his home

medications today: • Diovan HCT (valsartan) tablet 160 mg every morning • Glucophage XR

(metformin) 500 mg tablet twice daily with breakfast and supper

Before going out to dinner today, he took an over-the-counter Sinutab Maximum Strength Sinus

Allergy tablet because his sinuses were bothering him.

The STAT 12-lead electrocardiogram and cardiac profile blood work results ordered per the ER

protocol are negative for a myocardial infarction. The ER physician informs Mr. S. and his

girlfriend of the negative results and tells them that he has ordered a computed tomography (CT)

of the abdomen with IV and oral contrast. The CT result is positive for cholecystitis. The

informed consent is signed for a laparoscopic cholecystectomy, and Mr. S. is admitted. The

procedure is performed the following day.

His postoperative orders include a clear liquid diet to be advanced as tolerated to an 1800-calorie

American Diabetic Association (ADA) low-sodium diet. All his usual medications have been

reordered.

Answer 1

ASSESSMENT

subjective data

patient feels like an elephant is stepping on him

objective data

patient has extreme pain and alteration in vital signs [, tachycardia and tachypenia]

nursing diagnosis

unpleasant sensory and emotional experience arising from excessive pain related to cholecystitis

planning

after 8 hours of intervention,the patient will report pain is controlled

intervention

assess the character,location and seviority of pain -for effective management

administer analgesics as prescribed

administer antispasmodics as prescribed to relax smooth muscle

instruct the client to avoid gas forming foods and eat only small and low-fat meals to reduce pain related to gas formation and indigestion

encourage deep breathing to relax

prepare the client for surgical procedurs as prescribed -for effective management of cholecystitis

IMPLEMENTATION

Assessed the seviroity of pain

analgesics administered

antispasmodics administered

instructed the patient to avoid gas forming foods and fatty foods

encouraged deep breathing technique

prepered the patient for surgical management

evaluation

patient was able to report- pain was controlled

NAUSEA AND VOMITTING

nursing diagnosis

An unpleasant ,wavelike sensation in the back of throat ,vomitting related to indigestion of food

intervention

assess the seviority of vomitting

assess the level of dehydration

maintain NPO status during nausea and vomitting episodes

maintain nasogastric decompression as prescribed for excessive vomitting

administer anti emetics as prescribed

EVALUATION

patient was able to report reduced frequency of vomitting