(VM/GP/KL-V5)
Cultural considerations, ethnicity, occupation, religion, family support, insurance XXXXXXXXXX)
Socioeconomic/Cultural/Spiritual Orientation & Psychosocial Considerations/Concerns:
The patient is of Indian American decent, however they identify with their American culture more prominently. The patient cu
ently works
full time for an insurance company. Her highest level of education is a bachelor’s degree. She states that she practices Hinduism, which is an
important aspect of her culture. She has a great deal of family support from her husband, children, parents and siblings. The patient feels that
she is not excessively stressed out regarding her family situation because she has an abundance of support. She also feels connected to the
community through the activities her children are involved in. Through her work, the patient receives medical coverage for her hospital stay
ecause of her insurance policy. Regarding financial income, the patient stated that she felt financially stable based on the income both her and
her husband make through their jobs. The patient’s stability has allowed her to develop a strong sense of self. She does not feel any
psychosocial concerns regarding her or her family’s health and wellbeing.
The Social Determinants of Health focuses on an individual’s work and living situation as well as their quality of life, their age, and any risks
that may develop (Healthy People, XXXXXXXXXXThe patient is fortunate to have a strong sense of support from her family due to her home
environment and safe neighborhood. It is through these cu
ent situations that the patient is able to maintain a stable, positive lifestyle. One
aspect of the Social Determinants of Health that is of concern is the fact that the patient is considered a minority in their community. Although
they are financially stable, racial disparities may affect their overall physical and social health and wellbeing. The patient understands this and
does her best to become more aware of any potential risks to herself or her family.
History of Present Illness (HPI), Pathophysiology of Admitting Dx (Cite References) Medical, Surgical, Social History (1).
Cholecystitis and Cholelithiasis
The patient was admitted to the hospital due to experiencing increased upper abdominal pain and experiencing three days of excessive vomiting. The patient was
scheduled to have a consultation with a gastroenterologist later in the week, however the pain had become increasingly severe that she decided to seek medical
treatment at the emergency department. The patient has a history of experiencing symptoms from cholecystitis and cholelithiasis. Cholecystitis is refe
ed to as
experiencing inflammation of the gallbladder. Cholelithiasis occurs when the gallstones within the gallbladder obstruct the common bile duct, resulting in an
accumulation of bile collecting in the gallbladder, causing inflammation (Holman et al., XXXXXXXXXXUpon admission to the emergency department, the patient was assessed
y the physician, given an abdominal ultrasound and X-ray, as well as have a complete blood count obtained. The X-ray that was performed distinguished that the
patient had a 13.1 mm common bile duct dilation in the gallbladder. Suffering from cholecystitis can result in pancreatitis due to it potentially obstructing the pancreatic
duct. Additionally, cholecystitis can also result in a ruptured gallbladder, which can cause more severe peritonitis (Holman et al., XXXXXXXXXXWhen a patient’s common bile
duct is blocked, it results in their aspartate aminotransferase (AST), lactate dehydrogenase (LDH), and alkaline phosphatase (ALP) levels to increase. Based on the
patient’s lab results, they had an increased lipase, AST, and ALT levels. These lab values in addition to the results from the ultrasound and X-ray confirms the patient’s
diagnosis of cholelithiasis.
Medical History:
Type 2 Diabetes
The patient has a history of suffering from Type 2 diabetes mellitus. This condition occurs when an individual does not have sufficient insulin production from the
pancreas. Beta-cells are found in the body and cannot develop enough insulin to balance and maintain an individual’s glucose levels (Copstead & Banasik, XXXXXXXXXXThis
causes a great deal of risk for the patient because if their glucose levels increase significantly, they will develop hyperglycemia. Similarly, if their glucose levels are too
low, they will develop hypoglycemia. The patient’s blood glucose levels were slightly increased from the normal range, resulting in hyperglycemia. If untreated,
hyperglycemia can cause permanent damage to the patient’s blood vessels as well as the nerve endings located throughout the body (Holman et al., XXXXXXXXXXBecause the
patient’s blood glucose levels are increased, it is important to closely monitor their condition to decrease the risk of permanent damage.
Hypertension
The patient has a history of hypertension. This condition happens when an individual’s systolic blood pressure is above 140 mmHg and their diastolic blood pressure is
above 90 mmHg. Suffering from this condition for an extended period of time and not properly managing it can lead to some very severe complications such as
peripheral vascular disease which has a direct co
elation to damage to the heart, kidneys, and
ain (Holman et al., XXXXXXXXXXIt is imperative that individuals who have
diabetes mellitus maintain their blood glucose levels while also having hypertension. In order to better manage her hypertension, the patient is cu
ently taking blood
pressure medication as a means to decrease her normal blood pressure. The medication she is taking includes clonidine. The patient’s blood pressure upon admission
was 153/95. Although this increased blood pressure may have been caused by the excessive pain felt due to the cholelithiasis, it is important to continue to maintain this
pressure within a normal and healthy range.
Surgical History:
The patient does not have any surgical history. Given the patient’s condition, the physician may recommend performing an extracorporeal shock wave lithotripsy or a
cholecystectomy. Shock wave lithotripsy is used to
eak up stones. Cholecystectomy is a surgical procedure where the surgeon removes the gallbladder
laparoscopically (Holman et al., 2019).
Social History:
The patient denied that they had any inclination of harming themselves or others. They did not have a history of using any elicit drugs nor do they smoke cigarettes or
use tobacco. The patient denied the ingestion of excessive alcohol but stated that she drank minimally and socially. The patient has a strong support system from her
family and siblings. She is also supported by her husband, who accompanied her to the hospital. The patient stated that she did not have any mental or emotional
deficits. Based on the psychosocial analysis, the patient does not need any psychological refe
als cu
ently.
Chief Complaint
The patient was admitted due to increased
upper abdominal pain relating to
inflammation of the gallbladder caused by
gallstone blockage.
Admitting Diagnosis & Admission Date
The patient’s diagnosis included cholelithiasis with
iliary dilation of the common bile duct. The patient
was admitted with a 13.1 mm dilation of their
common bile duct caused by cholelithiasis. The
admission date was 5/1/2021.
Patient Information
(1)
Patient Initials: ME. AR.
Age & Gender: 40, Female
Height/Weight: Ht=67 in; Wt=80.7 kg
Code Status: Full Code
Living Will/ DPOA: Yes
Concept Map
Student Name: Jane Doe
Instructor: Dr. Kim
DATE Care Provided and UNIT: 5/7/21, ER
Erickson’s Developmental Stage Related to pt. & Cite References (1) *List and Discuss
specific stage (based on objective assessment)
According to Erikson’s stages of development, the patient is cu
ently in the generativity vs.
stagnation stage in their life. This stage ranges from 35-65 years old (Holman et al., XXXXXXXXXXIn this
stage, adults pursue a life of generativity, focusing on using life opportunities in a productive
manner and for developing a general concern for those around them. It also focuses on being able to
adapt to physical changes in the body and changes to one’s capabilities (Holman et al., XXXXXXXXXXIf an
individual is stuck in the stagnation aspect of this stage, they will have a difficult time accepting the
changes that are occu
ing to them physically and will lack the ability to be of service to others
(Holman et al., 2019).
Based on the assessment of this patient, they are in the generativity aspect of this developmental
stage. The patient has been able to maintain a stable job and income. Additionally, they have been
able to not only be a productive member in society, but they have navigated being able to adjust to
life with teenage children. The patient appears to have a strong sense of self and keen insight into
their environment. Given the patient’s cu
ent condition, it is truly beneficial that they are in the
generativity aspect of Erikson’s stage of development.
(VM/GP/KL-V5)
Key Diagnostic Tests (continued):
The patient scored a 35 on the Morse Fall Scale/Risk Screening, signifying that they are at a moderate risk of falling. Although the patient is able to ambulate independently, they required
minimal assistance when walking due to experiencing pain. They have not had any history of falling, however, being on pain medication increases their risk of being unstable and falling. It is
important that the nurse ensures that the patient always has their call light in place, the bed remains in the lowest position, and the side rails are up. The nurse should also educate the
patient on the importance of asking for assistance if she needs to get up from her bed. By implementing these interventions, the patient will remain safe and free of falls.
The patient had an ultrasound and X-ray performed on May 1, 2021 which distinguished that they had a 13.1 mm biliary dilation of the common bile duct. This dilation is a sign of
cholestasis which is often caused by an obstruction from a gallstone. Due to the patient’s condition, shock wave lithotripsy may be implemented to assist in
eaking up the gallstones that
have formed. If this does not work, a cholecystectomy can be performed which results in the removal of the gallbladder (Holman et al., 2019).
(VM/GP/KL-V5)
Patient Education (In Pt.) for Transfe
Discharge Planning
When evaluating the patient’s learning style, it was recognized that the patient thrived through visual and
auditory representations of information. Based on this information, discharge teachings have been developed to reflect a
visual, auditory, and written style. The education and instructions regarding her condition and foods to eat has been
printed out for her to take home. Although the patient still remains in the hospital, she