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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.|
|CURRENT MEDICATIONS:||· Amphogel 30 cc poqid· Furosemide 40 mg IV qd
· Aldactone 50 mg po bid.
|SUBJECTIVE/OBJECTIVE DATA: Per outgoing nurse
Increasing shortness of breath
No complaints of chest pain
Mild abdomen distention
She has no ankle swelling or edema noted.
Heart :normal S1 and S2 with a rate of 94.
Skin : Jaundice, Ascites
There is no peripheral edema.
|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)
Bedrest with bathroom privileges
Measure abdominal girth daily
Diet CHO, 30 g. Protein, 2g Na
|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
Serum Ammonia 70ug/dl
|PAST MEDICAL HISTORY|
|Type 2 Diabetes MellitusAlcohol Abuse|