Beverly F.

Sze

CASE STUDY NO. 2

A 59 year old patient is admitted to the hospital for 3 days. Patient Marita B. Bona Cruz is
married, with 3 children and they are all professional, patient is admitted in the hospital last
November 14, 2022 at 8:30 in the morning under the care of Dr. Palisoc, patient is admitted
due to non-healing wound in her left foot and fever for 1 week and decrease urine output.
Vital signs upon admission were blood pressure 70/50 mmhg, temperature of 39.0C,
Respiratory rate of 36 BPM, pulse rate of 120 bpm, 02SAT 89%. Upon arrival the patient is
pale, weak and cold and clammy. Dr. Palisoc ordered the following diagnostic. For CBC,
Serum electrolytes, RBC, ECG, Chest X Ray, Creatinine and ABG. The following are the
results of the Diagnostic. For CBC Haemoglobin is 90g/l, Hematocrit of 0.47, WBC 46x10/l,
Platelet count of 200,000, RBS result is 300 mg/dl, Creatinine Result is 376 mmol/l, serum
electrolytes result. Sodium 135 meq/l, Potassium 2.0meq/l, Chloride 105 meq/l. Chest X Ray
results revealed Normal Findings. ABG result was Ph 7.41, paco2 10, HCO3 55.
Immediately Dr. Palisoc instructed the nurse on duty to start the following medication
meropenem 2gm iv every 8 hours, paracetamol 300 mg iv every 4 hours rtc, salbutamol
nebulization 1 respule every 6 hours, levofloxacin 750 mg 1 tablet po, ketoanalogue plus
amino acid 2 tablet tid, gliclazide 60 mg 1 tablet po bid, levofloxacin 750 mg once a day,
dobutamine drip single concentration start at 15 gtts/min, start Potassium drip at 60 meqs of
potassium in 500cc of d5lr.

Start IVF of Pnss 1L for 8 hours and secure 3 units of PRBC because the patient is for blood
transfusion of 3 units of PRBC properly type and cross matched. Patient is away from her
family because her children are having their own family and her husband died 3 months ago,
still the patient is in denial that her husband was gone already and started drinking and
smoking since her husband died. Patient had a past medical history of pneumonia and
appendicitis. Her family history was her father died of Covid-19, and with co-morbid DM, and
Hypertension.

Answer the Following Question?

1. Based on the scenario above, what is your top 3 diagnosis for this patient? 10 points
Answer:
Diagnosis:
1. Infection
2. Diabetes Mellitus
3. Acute Post-infectious Glomerulonephritis

2. What laboratory finding that can support your top 3 diagnosis? 10 points
Answer:
1.) Infection: Presence of fever and increased WBC level of 46x10/l (normal value is (5
to 15× 10 /L)
(2.) Diabetes Mellitus: Presence of non-healing wound and increased RBS level of 300
mg/dl (Normal Value is 5 to 6.25 ×10/L)
(3.) APGN: Presence of decreased urine output and increased serum creatinine level
of 3.76 mmol/ l (Normal value is 0.6 to 1.3mg/ml or 53 to 115 mmol/ L)

3. Based on your 3 diagnoses, choose your top priority and make your basic
pathophysiology? 10 points
Answer:
● Insulin resistance and / or inadequate insulin secretions from pancreatic beta cells.

4. Based on your basic pathophysiology what medication is necessary to treat your top
diagnosis and give your rationale why you choose this medication? 10 points
Answer:
● Glimepiride
Therapeutic class: Antidiabetics
Pharmacologic class: Sulfonylureas

Action:
Lower glucose level by stimulating release of insulin from functioning pancreatic beta
cells, and may lead to increased sensitivity of peripheral tissues to insulin.

"I have chosen this medication because it has less adverse effects".

5. Based on the scenario above, what is your top 3 nursing diagnosis for the patient and
make your nursing care plan for your top 3 nursing diagnosis? 40 points.

Answer:
1. Ineffective peripheral perfusion as evidenced by non-healing wounds.
2. Ineffective coping related to denial of husband’s death and living alone as
evidenced by alcohol abuse.
3. Fluid volume deficit as evidenced by low blood pressure (hypotension) and
increased heart rate (tachycardia).

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION

Subjective Ineffective Short-term goal: Independent: Short-term
Data: peripheral ● After 8 hours ● Monitor the goal:
● The client is perfusion as of nursing client’s V/S, ● After 8 hours
admitted due to evidenced by intervention, the implement of nursing
non-healing non-healing client has stable interventions to intervention,
wound in her wounds. Vital Signs, regulate the the client’s vital
left foot specifically the client's body signs are
● Fever client's body temperature stable, has no
● Decrease thermoregulation within the more fever, and
urine output and wounds normal range. wounds is
were properly ● Maintain properly
healing. adequate healing.
Objective Data: peripheral Long-term goal:
V/S: Long-term goal: perfusion as ● The client
● Blood ● In the next two evidenced by has been very
Pressure: 70/50 months or so, strong pedal active and
mmhg the client will be pulses, normal doing her
● Temperature: able to do body activities of
39.0C activities of daily temperature, daily living and
● Respiratory living with no and intact skin. exercising with
Rate: 36 bpm discomfort, and ● Patients will no discomfort,
● Pulse Rate: wound that is demonstrate and wound has
120 bpm fully healed. appropriate fully healed.
● 02 Sat: 89% lifestyle
modifications to
Diagnostic support
Result Test: adequate tissue
● CBC perfusion such
Haemoglobin: as having
90g/l exercise
● Hematocrit: regimen and
0.47 alcohol
● WBC: 46x10/l cessation.
● Platelet ● Ensure that
count: 200,000 the patient is
● RBS: 300 adequately
mg/l hydrated and
● Creatinine maintain fluid
Result: 376 balance.
mmol/l Keeping the
body hydrated is
Serum important for
Electrolytes circulation and
Result: elimination.
● Sodium: 135 ● Infection
mEq/l control
● Potassium: measures are
2.0 mEq/ l implemented to
● Chloride: 105 avoid further
mEq/l spread of any
virus or bacteria
Chest Xray which can lead
Result: to contracting
● Revealed disease that will
Normal cause
Findings ABG ineffective
Result: peripheral
● Ph: 7.41 perfusion.
● PaCo2: 10 Monitor for any
● HCo3: 55 signs and
symptoms
associated with
these conditions
such as fever.
● Documents all
necessary
observations for
the patient's
 safety and care,
that can help the
patient get the
right care at the
right time.

Dependent:
● Should
administer all
the needed
medications,
including
antibiotics and
anti-diabetic as
prescribed by
Primary Health
Care Provider.

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION

Subjective Data ● Ineffective Short-term Independent: Short-term
coping goal: ● Using goal:
● As stated by mechanism as ● After 8 hours techniques such ● After 8 hours
the patient, she related to of nursing as active of nursing
started drinking husband’s interventions, listening, interventions,
alcohol and death and living patient will reflecting, open- patient
smoking after alone as recognize and ended recognized and
her husband’s evidenced by identify her questions, and identified her
passing about alcohol abuse irrational even silence, irrational
three months and smoking. behaviours and nurses can behaviours and
ago and she is implement foster trusting implemented
also living alone healthy coping relationships healthy coping
by herself mechanisms with patients mechanisms
because her that will and further that positively
children already positively explore barriers impacted her
have their own impact her daily to their ability to daily living.
family. living. cope.
● Provide Long-term goal:
Objective data: Long-term goal: stress-relieving ● Patient has
V/S: ● In the next 2 and relaxation been aware
● Blood to 3 months or techniques. with her
Pressure: 70/50 so, the patient After assessing irrational
mmhg will be aware which activities behaviours and
● Temperature: with her the patient uses knew just how
39.0C irrational themselves to to effectively
● Respiratory behaviours and control stress, manage them
Rate: 36 bpm knows how to the nurse can with healthy
● Pulse Rate: effectively offer available coping
120 bpm manage them options such as mechanisms.
● 02 Sat: 89% with healthy reading books, Patients has
coping music, expressed
Diagnostic mechanisms. distractions, and confidence in
Result Test: Patients will guided imagery. handling her
● CBC express ● Offer positive stressors or any
Haemoglobin: confidence in responses changes in her
90g/l handling her without false life.
● Hematocrit: stressors or any reassurances.
0.47 changes in her The nurse can
● WBC: 46x10/l life. also calm fears
● Platelet and prevent
count: 200,000 added stress by
● RBS: 300 commenting on
mg/l progress such
● Creatinine as improved
Result: 376 vital signs,
mmol/l activity levels, or
lab work.
Serum ● Ask the
Electrolytes patient how they
Result: dealt with
● Sodium: 135 difficulties in the
mEq/l past.
● Potassium: ● Patients may
2.0 mEq/ l need to be
● Chloride: 105 reminded of
mEq/l stressful hurdles
they handled in
Chest Xray the past and
Result: how they can
● Revealed apply the same
Normal problem-solving
Findings ABG and decision-
Result: making in
● Ph: 7.41 current
● PaCo2: 10 scenarios.
● HCo3: 55 ● Encourage
rest as well as
exercise.
Patients should
be instructed to
rest and try
relaxing
activities such
as warm bath.