Posted: November 18th, 2022

Case Study- Ms. Sato fundamentals of Nursing

Module 07 Content

In this second submission of your Course Project, you will be completing a health history, physical assessment of your client and determining their nursing diagnoses. This written assignment should include the following:

Health Assessment, Health History, and Nursing Diagnosis

A brief medical/health history
Summary of laboratory diagnostic results related to the illness/condition and what they mean
Summary of a head to toe physical assessment
Your nursing diagnosis
Ms. Sato is a 75-year-old Japanese American who speaks Japanese as a
primary language but is proficient in reading/writing English. She recently moved to a long-term care facility as she
was unable to adequately take care of herself at home. Ms. Sato is divorced and was a
housewife and caregiver for a son diagnosed with cystic fibrosis and type 1 diabetes at a young age. Her
two daughters live nearby and visit each week. Her past medical history includes colon CA, colostomy,
Helicobacter pylori infection, depression, hypertension, and osteoporosis. She wears glasses for reading.
Orders include:
Full resuscitation
Regular diet
Ambulate with gait belt and 1 standby Help
PT/OT daily
Change ostomy appliance PRN
Psychiatry consult
Medications Include:
Sertraline 50 mg PO daily
Alendronate 10 mg PO daily
Cholecalciferol 1 capsule (5,000 IU) daily
Metoprolol ER 100 mg PO daily
Clonidine 0.1 mg PO TID
Ms. Sato 1

Fundamentals of Nursing

Ms. Sato 2
Case Study- Ms. Sato
facility as she was unable to adequately take care of herself at home. Ms. Sato is divorced and was a
housewife and caregiver for a son diagnosed with cystic fibrosis and type 1 diabetes at a young age. Her
two daughters live nearby and visit each week. Her past medical history includes colon CA, colostomy,
Helicobacter pylori infection, depression, hypertension, and osteoporosis. She wears glasses for reading.
Orders include:
Full resuscitation
Regular diet
Ambulate with gait belt and 1 standby Help
PT/OT daily
Change ostomy appliance PRN
Psychiatry consult
Medications Include:
Sertraline 50 mg PO daily
Alendronate 10 mg PO daily
Cholecalciferol 1 capsule (5,000 IU) daily
Metoprolol ER 100 mg PO daily
Clonidine 0.1 mg PO TID
Part One- Medications:
Drug Name
Trade &
generic
name, dose,
route &
frequency
Pharmacological
& therapeutic
drug class &
Expected action
in the body
What
medical
diagnosis
is your
patient
taking
this drug
for? How
will it
help
them?
Side Effects &
Adverse
Reactions/
Complications/
Top drug
interactions
Nursing
Administration
Special
Instructions &
Assessments
Client
Education/
Assessment of
Medication
Effectiveness
(e.g. Pain Scale)
Ms. Sato 3
1.Sertraline
50 mg PO
daily
Pharmacological
: SSRI (selective
serotonin
reuptake
inhibitor)
Therapeutic:
Antidepressant
Expected action:
Inhibit neuronal
uptake of
serotonin in the
central nervous
system,
potentiating the
effects/ activity
of serotonin.
Ms. Sato
takes this
for her
depression.
This should
cause an
antidepress
ant action
and aid in
decreasing
her feelings
of
hopelessnes
s,
helplessnes
s, and fear/
anxiety.
Side effects:
Dizziness, dry
mouth, nausea,
upset stomach,
headache,
drowsiness,
sexual
dysfunction
Adverse
Reactions/
complications:
Suicidal
thoughts,
serotonin
syndrome, chest
palpations
Top
Interactions:MA
OI inhibitors,
drugs affecting
serotonergic
neurotransmitter
systems, other
SSRIs (serotonin
syndrome)
Periodically
reassess dose and
continued need for
therapy.
Administer single
dose in morning or
evening.
Assess for suicidal
tendencies and
serotonin sydrome
closely. Monitor
appetite and
nutritional intake.
Monitor sexual
dysfunction.
Monitor mood
changes.
May cause false
positive urine tests
for
benzodiazepines.
May take up to 4
weeks to be
effective.
Sexual
dysfunction is a
common s/s.
Instruct to take as
directed, when
you miss a dose
take ASAP and
return to regular
schedule.
Do not stop
abruptly.
May cause
drowsiness or
dizziness.
Avoid alcohol.
Maintain good
oral hygiene to
combat dry
mouth.
Emphasize the
importance of
follow ups.
2.Alendronat
e 10 mg PO
daily
Pharmacological:
Bisphosphonates
Therapeutic: Bone
resorption
inhibitors
Expected action:
Will inhibit
resorption of bone
via inhibiting
osteoclast activity.
Therapeuticreverse
progression of
osteoporosis,
Ms. Sato
has
osteoporosi
s; she is
prescribed
alendronate
to help
lessen the
effects and
progression
of
osteoporosi
s and aid in
bone
Side effects:
Nausea,
headache,
diarrhea,
constipation,
bloating
Adverse
reactions/compli
cations: Atrial
fibrillation,
blurred vision,
dysphasia,
abdominal
distension,
Assess patients for
low bone mass
before and during
use. Administer
first thing in the
morning with 6-8
oz of water, 30
minutes before
giving any other
medications,
fluids, or food.
Assess serum
calcium level
before and during
Ensure the patient
understands the
importance of
taking this
medication
exactly as
directed (30 min
before meals,
medication, or
fluids in the
morning). If a
dose is missed, or
accidentally
skipped, do not
Ms. Sato 4
lessening risk of
fracture
resorption. esophageal
cancer
Top Interactions:
Calcium
supplements,
antacids,
levothyroxine
therapy. take a double
dose and resume
as normal the
following day. Do
not stop taking
without
consulting the
provider. Remain
upright 30 min
following dose to
minimize
esophageal
irritation and aid
in digestion.
3.Cholecalcif
erol 1 capsule
(5000 IU)
daily
Pharmacological:
Fat soluble
vitamins
Therapeutic:
Vitamins
Expected action:
Cholecalciferol
requires activation
in the liver and
kidneys, it creates
the active form of
vitamin D3
(calcitriol).
Improved calcium
absorption.
Ms. Sato is
most likely
taking this
to aid in the
absorption
of calcium
for her
osteoporosi
s. Also
taken as
prevention
of vitamin
D
deficiency.
Side effects:
headache, dry
mouth,
confusion,
arrhythmias
Adverse
reactions/compli
cations: Toxicityhypercalcemia,
hypertension,
bradycardia, HF,
Pancreatitis ,
seizures,
Hypersensitivity
reactions
Top
Interactions:Chol
estyramine,
colestipol,
calcium
containing drugs,
corticosteroids
Take capsule once
a day. Assess for
signs of
hypercalcemia,
may increase risk
of arrhythmia and
seizures monitor
closely. Monitor
serum calcium,
phosphate, and
alkaline phosphate
concentrations
periodically.
Advise patient to
take as directed, if
a dose is missed
take it as soon as
remembered that
day or skip, do
not double doses.
Review diet for
foods high in
calcium and
vitamin D.
4.
Metoprolol
Pharmacological:
Beta blocker
Hypertensi
on.
Side effects:
constipation, dry
Monitor HR and
BP closely. Help
Teach patient to
take their pulse at
Ms. Sato 5
ER 100 mg
PO daily
Therapeutic:
Antianginals
antihypertensive
Expected action:
Block stimulation
of beta- adrenergic
receptors.
Decreased BP and
heart rate.
Metoprolol
should
decrease
HR and BP.
mouth, urinary
frequency,
nausea,
dizziness, heart
burn
Adverse
reactions/compli
cations: COPD:
bronchoconstricti
on (wheezing),
bradycardia,
fatigue,
hypotension,
dizziness,
fainting,
pulmonary
edema
Top Interactions:
General
anesthesia, IV
phenytoin,
verapamil,
digoxin, alcohol,
antihypertensives
with ambulation to
avoid falls/
orthostatic
hypotension, move
positions slowly.
Monitor intake and
output ratios and
daily weights.
Assess often for
signs of HF. Take
pulse before
administering if
<50 bpm do not
administer.
Administer with
meals or directly
after eating.
home, do not take
if HR < 60 bpm.
Teach patient to
take blood
pressure, hold for
SBP < 110
mmHg. Change
positions slowly,
may take a few
weeks for full
therapeutic effect.
Take as advised
by prescriber.
Take with meals
or directly after
eating.
5.Clonidine
0.1 mg PO
TID
Pharmacological:
Adrenergic
(centrally acting)
Therapeutic:
Antihypertensive
Expected action:
Stimulate
alpha-adrenergic
receptors in CNS.
Decrease BP,
decrease in pain
This could
be
prescribed
to help with
both
hypertensio
n and pain
related to
the colon
cancer.
Side
effects:Dizziness,
lightheadedness,
drowsiness, dry
mouth,
constipation.
Adverse
reactions/compli
cations:
Bradycardia,
hypotension, dry
mouth, dry eyes,
withdrawal
phenomenon,
paresthesia
Monitor intake and
output ratios and
daily weight.
Assess for edema.
Monitor for fever,
BP, pulse and
respirations before
and during
treatment.
Administer last
dose of the day at
bedtime. Do not
crush, break, or
chew.
Take as directed
by prescriber and
take at the same
time each day. Do
not take more
than the
prescribed dose in
24 hours. May
cause drowsiness,
avoid sudden
changes in
position. Maintain
good oral hygiene
to combat dry
mouth.
Ms. Sato 6
Top Interactions:
CNS depressants,
alcohol, opioid
analgesics,
antihistamines
Labs and Diagnostic Tests:
1. Serum calcium levels: Normal range- 8.5-10.5 mg/dl, This would be done to test for
conditions such as hypercalcemia and hypocalcemia. Since Ms. Sato has a history of
osteoporosis and takes supplements containing calcium. This test will help ensure safe
therapeutic levels and see if intervention of any kind is needed. Osteoporosis is caused by
low levels of calcium in your bones, this test could come back low.
2. Basic metabolic panel: This test is commonly used to measure glucose, sodium,
potassium, calcium, chloride, and much more. This can be used in Ms. Satos case to
determine blood sugar value, electrolyte and fluid balance, and kidney functioning. This
can also be used to monitor the effects from medications she is currently taking and aid in
early detection of possible concerns needing interventions.
3. Urinalysis: This could be used to determine early signs of disease as well as monitor for
diabetes and kidney disease. Normal values should have a gravity between 1.005-1.025,
be negative for glucose, ketones, blood, proteins, bilirubin, white blood cells, casts, red
blood cells, and crystals. Urine should also appear clear- slightly hazy and be pale yellow
to amber. Ms. Sato may not show any abnormal labs for this testing but it can provide a
baseline for future changes.
4. Urea breath test: Ms. Sato may need to perform this testing more than once due to her H.
pylori infection. This test is done to measure the release of carbon and detect the infection
Ms. Sato 7
and severity of it. Typically the test should be negative but in Ms. Satos case it will most
likely come back positive until the infection is properly eradicated.
5. CBC: A complete blood count would be done for this client for a variety of reasons, and
to provide a baseline of the client’s current condition upon admission. A CBC is used to
evaluate overall health so would be useful in Ms. Satos case, it can also be used to detect
a wide range of disorders and presence of infection. Since Ms. Sato has an infection; her
white blood cell count may show higher levels.
Ms. Sato 8
References
Vallerand, A. H., Sanoski, C. A. (20220518). Davis’s Drug Guide for Nurses, 18th Edition.
[VitalSource Bookshelf 10.2.0]. Retrieved from vbk://9781719648127

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