Case Study Grid

912 words - 4 pages

unning head: CASE STUDY GRID


Case Study Grid “Case History of Debbie”
Janet Ibrahim
September 21, 2015
Dr. Sherrily Mulleneaux

Case Study Grid “Case History of Debbie”

Five factors that demonstrate nursing needs:

1. Nutritional maintenance
2. Post-operative pain and nausea
3. Lacks knowledge about the importance of self-breast exams
4. Concerned about her and family’s future (2 daughters)
5. Emotional abuse from spouse

Nursing Diagnosis 1: Pain (Acute)

Rationale: Common among cancer patients. This is proved by various testimonies of Class V cervical cancer patients. Acute pain results from the activity of cancer cells and is related ...view middle of the document...

Nursing Diagnosis 2: Imbalanced Nutrition: Less than body requirements

Rationale: Less than body requirements actual metabolic needs in excess of intact with weight loss R/T to increased caloric requirements and difficulty and absorbing sufficient calories secondary to cancer.

Desired Outcome 1

Desired Outcome 2

Nursing Intervention 1

Explain the need for increased consumption of carbohydrates, fats, proteins, vitamins, mineral and fluids. Dietitian consultation, monitor food intake.

The patient will progressively gain weight toward desired goal with in three to five days post operatively.

The patient will eat daily nutritional requirements in accordance with activity level and metabolic needs as soon as they are able to ambulate and take food post operatively.

Nursing Intervention 2

Ascertain the patient’s food preferences, provide the patient with high- protein high –calorie, nutritious finger foods and, drinks that can be readily consumed, as appropriate.

Patient will identify nutritional requirements and consume adequate nourishment within time of discharge from the hospital.

Recognize factors of contributing to underweight, be free of signs, which may have ongoing factors involved and may take 3-6 months more or less.

Evaluation method

Nursing Intervention 1 – Patients nutritional status indicator, by the amount of food and fluid intake/Body mass index/ Weight-height ratio/Hematocrit levels, having steady improvement in weight gain. Lab tests such as: serum albumin > than 3.5, prealbumin, serum total protein, serum ferritin, transferrin, H&H, and electrolyte levels stable daily.

Percentage of food intact gradually increases over a consistent period of three days.

Nursing Intervention 2 – Patient starts to Adapt and explores new types of nutritious foods to consume, and shows a willingness to do so. Physical signs of malnutrition resolving.

Patient begins to take small frequent meals of foods with increased calories and protein.


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