Cani please get a ONE CONCEPT MAP with TWO nursing diagnosis
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Case Study: Client Background Biographical data: Demographic: Age: 38 Marital Status: married Gender: Female Educational Level: High School Diploma Height: 5ft Sin Occupation: homemaker Weight: 165lb Current Health Status: Cultural Consideration: Diagnosed by ultrasound with cholelithiasis and Language: English cholecystitis and underwent subsequent laparoscopic Ethnicity: African American cholecystectomy Nationality: American History: Psychological/social support Culture: American Married with 3 children aged 9, 13,16 yr Past History: Mother lives nearby Medical : gravida 3,para 3 Family History: Surgical: Tonsillectomy Mother: HTN Father died of cancer at 63yr Nursing Report: Mrs. Mckinnon, Claire, 38 y/o presented to ED this morning with complaints of severe right upper quadrant pain and 3 days of nausea and vomiting. She has no medical history. Ultrasound revealed Cholelithiasis and Cholecystitis. She underwent uncomplicated Laparoscopic Cholecystectomy. She received Morphine 2 mg IV for pain rated 8/10, 30 minutes ago. She has not voided since surgery, she is tearful and anxious. Her husband is in the waiting room and was with her in the Recovery Room, she has three children at home. Her Vital signs prior to transfer were BP-137/76, Pulse- 88, RR-20. PROVIDER’S ORDER Diagnosis: Postop Cholecystectomy DATE TIME Allergies: NKDA ORDER Vital Signs: Q15 min x 4; 430 min x4 11/10/2020 4:30PM PROVIDER’S ORDER Con’t Q1 hr x 4; 24 hr if stable Diet: Clear liquids, progress as tolerated Activity: Elevate head of bed, ambulate as tolerated IV therapy: Potassium 20 mEq in D51/2 NSS 1L at 100ml/hr, convert to Saline lock when tolerating fluids Medications: Primaxin 500mg 46 hour x 4 doses Morphine 2mg IV q2 HR PRN mild pain Percoset 2 capsules 29 9 4 hour PRN pain when tolerating Fluids Metoclopramide 10mg IV q 6 hr prn nausea Diagnostic Studies: AM Labs: AST, ALT, CBC, BMP Treatments: Straight cath x 1 if patient has not voided 6 hr post procedure Change dressing as needed Knee-high elastic stockings, sequential compression pump stockings
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