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Nursing Management Case Study Analysis: Laennec’s Cirrhosis
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Case Study: Laennec’s Cirrhosis | ||||
Ms. Janet Brook | Date of Birth: 12/20/1966 | Home Phone: (111) 111-1111 | ||
ADMISSION DIAGNOSIS: Laennec’s cirrhosis | ||||
Chief Complaint: Increasing Shortness of BreathMs. Janet Brook, was admitted with the diagnosis of Laennec’s cirrhosis. During report at 3:00 pm you find that she is jaundiced, has ascites, and is experiencing increasing SOB. Vital signs at 1:30 pm were T. 99 P. 94 R 34 B/P 140/90. The vital signs are consistent with previous recordings. You get out of report at 3:30 pm. | ||||
MEDICATION/FOOD ALLERGIES: | Penicillin | |||
CURRENT MEDICATIONS: | · Amphogel 30 cc poqid· Furosemide 40 mg IV qd
· Aldactone 50 mg po bid. |
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SUBJECTIVE/OBJECTIVE DATA: Per outgoing nurse
Increasing shortness of breath No complaints of chest pain C/O Constipation Mild abdomen distention She has no ankle swelling or edema noted.
Heart :normal S1 and S2 with a rate of 94.
Lungs: clear. Skin : Jaundice, Ascites
There is no peripheral edema.
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OrdersParencentis scheduled for 1630 hrs
VS q 4 hrs Neuro checks q 4 hrs CBC, serum ammonia, AST, ALT, PT today(Labs drawn during first shift) Saline Lock Bedrest with bathroom privileges Weigh Daily Measure abdominal girth daily Diet CHO, 30 g. Protein, 2g Na |
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VITALS SIGNS | ||||
BP: 140/92HR: 94RR: 34 T: 99PULSE OX: 90% | ||||
Patient is divorced.Lives with 2 teenage children 15 (daughter) and 17 (son). | Lab results 1500 hrsPT 40 sec
WBC 3500/mm3 AST 100U/L Serum Ammonia 70ug/dl Platelets 100,000/mm3 ALT 500U/L Hgb 10.6g/dl Hct. 30% |
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PAST MEDICAL HISTORY | ||||
Type 2 Diabetes MellitusAlcohol Abuse |