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Nursing Case Study

Nursing Case Study

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1. Introduction

This paper is a case study that will involve a closer analysis of the medical condition of a patient who is a 38 year old Caucasian female in mild distress. She is neat and clean, communicates her concerns and needs well. She complains of urine leakages over the past month or so. There is no much information at the moment thus a careful analysis of the current scare details will be used to come up with her diagnosis.

2. Background

She has been suffering from leakages during sessions at the gym, when lifting her children and heavy shopping bags, and upon laughing hard or sneezing. The patient is feeling self-conscientious and mildly anxious. Leakages vary from mild to a moderate amount that can cause embarrassment. She reports that she has resorted to wearing panty liners just in case. The patient hopes to get the proper medical attention to cure her condition because it is interfering with her daily activities and responsibilities.

3. Nursing Process

3.1 Assessment

P.M has been admitted for complaining of inability to control urination. Her 64 year old mother has high cholesterol challenges and also with an irritable bowel syndrome. Her father is 67 years old and also with glaucoma while the paternal grandfather who is 85 years old has various conditions like arthritis, COPD and dementia. The maternal grandfather is 81 years old and suffers from dementia and depression. Her 30 year old sister has no known medical condition while the sister – 34 years old also has borderline high cholesterol. Below are the key points that help in understanding the patient’s background and the approach to diagnosis and treatment.

  • To begin with, she has been married for 7 years.
  • Lives with her husband and her 4 year old daughter and 3 month old son.
  • Husband works for PSE&G.
  • Maintains a healthy diet.
  • Close family ties.
  • Close family ties.
  • Large circle of friends
  • Active member in her community and church.
  • Enjoys outdoor activities
  • Listens to classical music
  • Plays the violin
  • Enjoys traveling, but has not traveled since she became pregnant in 2013.
  • Patient does not smoke or consume alcohol.
  • Maintains a healthy diet.
  • Keeps well hydrated
  • Drinks 1-2 cups of caffeinated coffee in the morning
  • Juices her fruits and vegetables.
  • Participates in cardio aerobic step classes and kick-boxing classes 4 times a week
  • Enjoys yoga on Sunday mornings

P.M is currently prescribed to taking medicines and drugs like Multivitamin at the rate of 1 tablet on a daily basis to maintain her health, 1 tablet of Caltrate 600+D Calcium Supplement and Omega-3 (500mg tablets) 2 tablets also for health maintenance.

Description from the information provided ,This is given as the diagnosis result. She has diarrhoea and abdominal pain. At times, the bowel sounds are heard increasing. She also has anxiety characterized by narrowed attention focus.She has cases of recurring pain from past incidences.Description from the information providedVery concerned about the lack of help around the house. Discussed resources available for post-surgical recovery period. Patient verbalised understanding and appeared less anxious.

Colon Cancer
Leak of colon-anal anastomosis

3.3 Plan

The plan is to prioritize pain as the most urgent medical condition for P.M. The desired outcome is to minimize it within an hour. This will be achieved through: Performing a comprehensive evaluation of discomfort to determine pain location, features, onset/duration, frequency, intensity or severity of discomfort, and stressful aspects. Using therapeutic communication strategies to recognize the discomfort encounter & convey approval of the individual's reaction to discomfort. Exploring her knowledge and beliefs about discomfort, considering her social impacts on discomfort reaction and determining the impact of the discomfort encounter on total well being (e.g., sleep, appetite, activity, knowledge, mood, relationships, performance of job, and role responsibilities). Exploring with individual aspects that relieve/worsen discomfort will also be a good intervention.

3.4 Evaluation

The pain management activities for P.M involved certain levels of risk management. The efforts of managing pain also included a thorough historical analysis of P.M's medical history to get maximum details on how long she has suffered from chronic pain and possible leading events. The brief pain inventory tool was utilized to establish P.M's concerns. Worth noting is that the ORT tool was also used to gauge P.M's burden of risk prior to her prescription of the opioid medication. A proper documentation of the treatment process was also maintained after her opioid therapy process commenced. She is in a stable condition after being given medication including; Na 137 mEq/L, K 4.1 mEq/L, Cl 100 mEq/L, Hgb 12.1 g/dL, Hct 34.7, WBC 7.1, TSH 0.45 mIU/L, Free T4 0.71 ng/dL, Free Anti-TPO antibody negative, CO2 24 mEq/L, BUN 10 mg/dL, Glu 85 mg/dL, MCV 90 m3, Ca 8.7mg/dL, Mg 1.9mg/dL, PO4 2.6 mg/dL, albumin 3.7 g/dL, ASR 20 IU/L, T. Bili 0.3 mg/dL, Alk phos 60 IU/L, Cholesterol 168 mg/dL, LDL 128 mg/dL, HDL 82 hg/dL, triglycerides 57 mg/Dl.

4. Reflection

The diagnosis outcomes for P.M were partially fulfilled as others will take a longer period of time to clearly evaluate before making candid conclusions. I can confirm that P.M was in a stable condition at the time that I took over. Though she was asleep, she had been able to verbalize her painful conditions and the discomfort she was feeling. She even mentioned that she does not have nausea but was rather drowsy. I also took note of her willingness to follow the nursing care plan in order to have her health improve.

5. Conclusion

This nursing diagnosis has provided details about P.M’s personal and family history experiences/responses to the various health conditions and required medical procedures. It has provided the justifications foundation for choice of medical treatments utilized by the nurse to accomplish the desired results for which the health professional has responsibility.

6. Recommendations

  • It is recommended that the patient must be taught by the caregiver on the various factors that cause urine leakage and bowel incontinence.
  • It is highly recommended for the patient to be taught on the significance of the body fluid and presence of fiber in her diet in order for her to sustain a bulky stool.
  • The patient should also be educated on the need to establish her proper time that is regular for bowel evacuation.
  • Maintains a healthy diet.
  • In teaching the patient, it is recommended that the caregiver should make use of the fecal device to check and demonstrate incontinence device as necessary.
  • The patient must be taught to manage any forms of irritations at the perianal area by making use of the barrier ointment moisture.
  • It is also recommended that PM should also be informed on her need to regularly exercise.


Ackley, B. J., & Ladwig, G. B. (2014). Nursing diagnosis handbook: An evidence-based guide to planning care. Begin, L. (2010).

The nursing student’s practical guide to writing care plans. Retrieved from http://www.bristolcc.edu/students/writingcenter/forms/project.pdf

Carpenito-Moyet, L. J. (2007). Nursing diagnosis: Application to clinical practice. Philadelphia, Pa: Lippincott Williams & Wilkins.

Carpenito-Moyet, L. J. (2006). Handbook of nursing diagnosis. Philadelphia: Lippincott Williams & Wilkins. Comer, S., Jaffe, M. S., Teton Data Systems (Firm), & STAT! Ref (Online service). (2005). Delmar's geriatric nursing care plans. Australia: Thomson/Delmar Learning.

Dossey, B. M., Keegan, L., & American Holistic Nurses' Association. (2009). Holistic nursing: A handbook for practice. Sudbury, Mass: Jones and Bartlett Publishers.

Gulanick, M. (1997). Nursing care plans: Nursing diagnosis and intervention. St. Louis: Mosby. Gulanick, M., & Myers, J. L. (2011). Nursing care plans: Diagnoses, interventions, and outcomes. St. Louis, Mo: Elsevier Mosby.

Ladwig, G. B., & Ackley, B. J. (2014). Mosby's guide to nursing diagnosis. Schultz, J. M., & Videbeck, S. L. (2009). Lippincott's manual of psychiatric nursing care plans. Philadelphia: Lippincott Williams and Wilkins

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