Medical-Surgical Nursing:Assessment and Managementof Clinical Problems 9th Edition by Sharon Lewis,Shannon Ruff Dirksen,Margaret McLean Heitkemper,Linda Bucher

Exercise 13

Case study: Stress Patient Profile M.J., a 26-year-old female single secretary, is admitted to the hospital with right lower quadrant pain rated as 9 on a scale of 0 to 10; 10 to 12 watery, blood-streaked stools in the past 24 hours; and a low-grade fever. She has a 7-year history of inflammatory bowel disease. Subjective Data Patient relates the following:
• She has been hospitalized four times in the past year.
• She is not currently working because of the illness and has no income.
• She has no insurance.
• Her boyfriend has lived with her for 2 years.
• She does not want her boyfriend to visit because she thinks he has enough problems of his own.
• She has been in bed for the past week because of weakness, nausea, and malaise and has been crying and depressed. Objective Data
• Height: 5 ft, 6 in (168 cm)
• Weight: 104 lb (47.3 kg)
• Hemoglobin: 10.5 g/dL (105 g/L)
• Hematocrit: 30%
• Temp: 100°F (37.8°C)
-Priority Decision: What is the priority nursing diagnosis for M.J.on admission?