Patient Case Study
NK is a 40 year old female, wgt-138 lbs, hgt-5.7. Denies anyallergies.
She is married, works as an office manager for a large insurancecompany. She has three children, 2 boys (16, 14) and one girl (11).They live in Hackensack NJ in home. Her husband is an accountexecutive at a local branch of Bank of America. He is currently ona business trip and will be home in 3 days.
NK – insurance is Horizon Blue Cross and Blue Shield. NK hasbeen coughing and sneezing for over a week and has
self diagnosed herself for the “flu”. She believes she has theflu because everyone in her office has been sick and out of workfor the past week and half. Currently, NK has not missed any workand has been caring for the children by herself. Tonight, she callsher sister and tells her, “I am completely exhausted, I have beencoughing all day and night and now my chest is burning.”. Hersister insists she visits a hospital and convinces NK to go toEmergency Room
In the ER she is seen by triage nurse, and Nurse Practitioner.NK is admitted to the hospital for diagnosis a possible diagnosisof bilateral pneumonia.
Vital Signs
B/P 100/50
HR-98 Respirations –
Temp – 101.3
20
Admitting orders:
Vital Signs every 4 hours.
IV- Normal Saline @100cc/hr.
OOB with assistance
Regular Diet
Labs – Stat – CBC, chem.- screen
Blood cultures, U/A & CS, pregnancy test. Diagnostic tests -Stat – Chest x-ray
Meds
Colace 100mg po once a day
Multi-vitamin po daily
Crestor 20 mg po daily
Levofloxacin 250mg/50cc IVSS every 12 hours
1) Write an objective Head to Toe Assessment based upon thepatients presenting symptoms
2) What psychosocial issues would you be concerned with for thispatient and how would you address the issues.
3) List three nursing diagnosis for this patient
