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Patient Case Summary

Decent Essays

The following paper will be on the health status and nursing care for patient J.S. Throughout the paper, the reader will be presented with patient information such as: patient history of present illness, pathophysiology of illness, physical nursing assessment, functional health pattern assessment as discussed with patient, laboratory data, applicable nursing diagnoses, and a care plan for two diagnoses. In conclusion will be a brief summary and evaluation of what the author learned from this experience.
Patient History of Present Illness
Patient J.S was admitted to Winchester Hospital after falling at home and experiencing shortness of breath. Patient was diagnosed with a urinary tract infection and a right ureteral calculus. The patient …show more content…

However the patient was brought back in to the ED after the fall at home. The patient stated that he was siting on the edge of his bed attempting to change his Foley bag when he slid off and landed on the floor. He was found on the floor approximately three hours after and taken to the hospital. As a result of the fall the patient also has skin tear on his left upper arm. Mr. J.S. lives at home with his wife who is on hospice care for pancreatic cancer. Patient ambulates with a cane and walker. Mr. J.S has a history of GERD, HTN, MRSA-NARES, hyperlipidemia, abdominal surgery, mild myocardial infarction, chronic leukemia, enlarged prostate, sciatic or about 1 month, CLL with immune thrombocytopenia and splenectomy, diverticulosis, bowel obstruction, open cholecystectomy, lysis of adhesions, incisional hernia repair (12/12/2012), BPH with indwelling Foley. Family decided to take him off of hospice care and he will remain full code. At the beginning of the shift the patient was very tired, and did not seem …show more content…

The cause is unknown. However, there is an increased incidence in males. There are four types of stones; calcium (oxalate of phosphate), struvite, uric acid and cystine. The most common type (70-80%) is calcium stone. These stones are usually caused by an increased concentration of calcium in the blood. The causes and treatment for stones vary depending on what type of stone it is. Factors such as; high serum and urine level of stone components, urinary tract infection and the ph of the urine and dehydration all contribute to the formation of a stone. The main cause struvite stone is UTI, due to a certain enzyme that some bacteria secrete. Formation of the stone requires that the urine be supersaturated. If there is a higher concentration two ion in the urine they are more likely to precipitate. The formation of a stone usually begins with small clusters of crystals. Most crystals will pass because the force holding them together is not strong enough. Larger ion clusters however, form nuclei and become strong enough to stay together and overcome the tendency of ions to move apart. Once stable, the stone will continue to grow. The stone can become logged anywhere in the urinary tract if it is greater than 5mm, if the stone is less than or equal to 5mm the stone will usually pass on its own. Mr. J.S. has a few contributing factors to the formation of his stone. According to the book, Pathophysiology, “Obstructive

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