Mrs. Vera W. is a 60-year-old white woman, who emigrated from Germany to the United States at the age of 18. She has come to her primary care physician's office with her daughter. She tells you, "My daughter made me come here because I have had bad stomach pains for about 6 weeks." After you ask about the character, onset, location, duration, severity, and pattern of the pain as well as associated symptoms (COLDSPA), such as what relieves the pain and what unctions are affected by pain, you learn the following information. The pain is aching epigastric pain, fairly continuous, and worse at night. It radiates to her back when she lies down. The pain gets progressively worse, is not affected by eating, and interferes with her daily function (it prevented her from attending her grandson's birthday party and it also wakes her up at night). In addition, in the interview, Mrs. W. relates loss of appetite, mild nausea, heartburn, and fatigue. For the past several months she has felt full soon atter beginning a meal. She tells you that she was afraid to tell her doctor this because "he always says I worry too much.” A review of Mrs. W.'s chart discloses that she had four normal vaginal deliveries, several bladder and kidney infections, a total abdominal hysterectomy at age 50 for uterine fibroids, cholecystectomy at age 55, two episodes of deep vein thrombosis in the past few years, allergy to penicillin, and stomach sensitivity to medicines (e.g.. aspirin). Four years ago she had gastric endoscopy and upper gastrointestinal (Gl) barium swallow studies for complaints of heartburn and difficulty swallowing. The results revealed delayed esophageal peristaisis. Mrs: W. takes estrogen and calcium daily, (in the form of Tums) as recommended by her physician as a source of hormone and calcium after surgical, menopause. She tells you that she has recently started to take acetaminophen once sometimes twice- daily in the hope that this will relieve her pain. She has had mild temporary relief as a result. Mrs. W,'s family history reveals that her mother died at age 58 from "liver problems after having halt her stomach removed. " She says she does not smoke, drink, or use illegal drugs. She says that she has eaten the same diet all her life. "I eat good German food, a lot of potatoes and meats. My children tell me I should eat more vegetables and drink more water, but I don't like fruits and vegetables and I'd rather drink coffee." In response to your question about exercise, you learn that Mrs. W. walks to the post office every day, and "I pick up atter my husband around the house- does that count?" You comment that Mrs. W. looks upset, and she tells you that she Is very concerned about her pain. "I have always been strong and healthy, and now I am getting old and sick. It is depressing. Your physical assessment reveals a firmly palpable left supraclavicular node, approximately 2 cm in diameter, nonmobile, and nontender, as well as the following abdominal findings; abdomen round and symmetric, hysterectomy scar, striae, umbilicus in the midline without inflammation or herniation, slight midline pulsation in the epigastrium. Soft bowel sounds are heard in all four quadrants; no audible bruits. Generalized tympany percussed throughout; span of liver dullness is 13 cm over the MCL, splenic dullness at the 10th intercostal space (ICS). The abdomen is soft and tender to palpation in the epigastrium; the liver edge descends 2 cm below the right costal margin (RCM) on deep inspiration; no splenomegaly is noted. Questions: Work through the steps of analyzing the case study data.
1. Identify the subjective and objective findings.
2. Draw inferences and desired outcomes
3. Make possible nursing diagnosis
4. Make nursing interventions
5.Identify the defining characteristics,
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