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John Richardson Cirrhosis case study -Complete Solutions (Graded A)

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CIRRHOSIS CASE STUDY 2Cirrhosis John Richards, 45 years old Primary Concept Nutrition Interrelated Concepts (In order of emphasis) 1. Fluid and Electrolyte Balance CIRRHOSIS CASE STUDY 32. Per ... fusion 3. Cognition 4. Clinical Judgment FUNDAMENTAL Reasoning Case Study: STUDENT Cirrhosis History of Present Problem: John Richards is a 45-year-old male who presents to the emergency department (ED) with abdominal pain and worsening nausea and vomiting the past three days that have not resolved. He is feeling more fatigued and has had a poor appetite the past month. He denies any ETOH (alcohol) intake the past week, but admits to episodic binge drinking on most weekends. John weighs 150 pounds (68.2 kg) and is 6'0" (BMI 17.6). You are the nurse responsible for his care. Personal/Social History: John is single, has never married, and lives alone in his own apartment. He has struggled with heroin use/abuse in the past, but has not used in the past two years. John is currently unemployed and has no health insurance. He was diagnosed with hepatitis C ten years ago but has had minimal follow-up medical care since. What data from the histories is RELEVANT and has clinical significance to the nurse? RELEVANT Data from Present Problem: Clinical Significance: Fatigue Lack of appetite Hepatitis C He has not been complying with This warning and signs and symptoms indicate the presence of complications with the patient’s G.I system (Przybyłkowski et al., 2014). These vital signs also direct the nurse on which tests to carry out on CIRRHOSIS CASE STUDY 4prescriptions Malnourishment Nausea and vomiting the patient. RELEVANT Data from Social History: Clinical Significance: He is living alone History of heroin use He is unemployed and has no health insurance This history provides the baseline of the present habits of the patient From this history, the nurse can identify priority and treatment Mismanaging hepatitis and continued loss of alcohol causes further complications like liver damage(Przybyłkowski et al., 2014). Developing Nurse Thinking by Identifying Significance of Clinical Data Current VS: P-Q-R-S-T Pain Assessment (5th VS): T: 100.5 F/38.1 C (oral) Provoking/Palliativ e: Nothing/nothing P: 110 (regular) Quality: Ache R: 20 Region/Radiation: RUQ/epigastrickeith RN cirrhosis CIRRHOSIS CASE STUDY 5BP: 128/88 Severity: 6/10 O2 sat: 95% RA Timing: Continuous Orthostatic BP’s: Position: HR: BP: Lying 110 128/88 Standing 132 124/80 What VS data is RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT VS Data: Rationale: Temperature : 100.5 (oral) Pulse rate : 110 (regular) RUQ pain Orthostatic changes The rising pulse rate and temperatures indicate the presence of infection and pain Current Assessment: GENERAL APPEARANCE: Appears uncomfortable, body tense, occasional facial grimacing RESP: Breath sounds clear with equal aeration bilaterally, nonlabored respiratory effort CARDIAC: Pink, warm [Show More]

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