Molly McBurn is a 58-year-old morbidly obese woman who arrives at the Emergency Department complaining of abdominal pain of an 8/10. She states this pain has been progressively getting worse over the last 2 days, and she is also experiencing nausea and vomiting.

QUESTION

Molly McBurn is a 58-year-old morbidly obese woman who arrives at the Emergency Department complaining of abdominal pain of an 8/10. She states this pain has been progressively getting worse over the last 2 days, and she is also experiencing nausea and vomiting. She has a medical history of diverticulosis, osteoarthritis in both knees, and admits to smoking one pack of cigarettes per day for the past 42 years as well as drinking “sometimes every day.”

Molly’s admitting lab results include the following:

Labs:

Blood cultures positive – gram negative rods

CBC CMP

WBC

12

Albumin

1.8

Neutro

77

Alk Phos

302

Bands

2

ALT

173

Lymph

12

BUN

22

Mono

10

Creatinine

1.1

Eos

0

CO2

26

Baso

4

Na

140

RBC

4.6

Cl

108

Hct

32

K

3.6

Hgb

11.3

Glucose

210

Platelets

188

Total Bili

2.4

Amylase

415

Total Protein

4.8

Lipase

242

Ca

9.6

PT/INR

14/2.6

Thyroid stimulating hormone (TSH)

5.6

Magnesium

1.4

Serum triiodothyronine (T3)

62

Free thyroxine (FT4)

0.5

Answer the following questions:

• Which values are abnormal, and what could they indicate?
• What are three nursing diagnoses with three interventions and rationales each that would need to be added to the care plan?

ANSWER

Nursing Diagnoses, Interventions, and Rationales for Molly McBurn: A Case Study

Introduction

In this essay, we will discuss the case of Molly McBurn, a 58-year-old morbidly obese woman who presents at the Emergency Department with complaints of severe abdominal pain, nausea, and vomiting. We will analyze her abnormal lab values and identify three nursing diagnoses along with corresponding interventions and rationales for her care plan.

Abnormal Lab Values and Possible Indications:

Albumin (1.8 g/dL): Molly’s low albumin level suggests malnutrition and poor protein synthesis due to her morbid obesity, inadequate dietary intake, and chronic diseases. This abnormality indicates an increased risk of fluid imbalance, impaired wound healing, and heightened susceptibility to infections.

WBC (12 x 10^9/L) and Neutrophils (77%): Elevated WBC count and neutrophilia indicate an acute bacterial infection, as confirmed by positive blood cultures. Molly’s abdominal pain and associated symptoms further support this diagnosis.

Alkaline Phosphatase (ALP) (302 IU/L): Molly’s ALP level is higher than the normal range (40-150 IU/L), which could suggest liver or bone disease. Given her history of obesity, alcohol consumption, and smoking, liver pathology is a possibility and warrants further investigation.

Nursing Diagnosis 1: Imbalanced Nutrition: Less Than Body Requirements Interventions

Monitor and document Molly’s daily dietary intake, including portion sizes and meal times, to assess nutritional adequacy (Bailey, 2021). Rationale: Accurate assessment of dietary intake helps identify nutrient deficiencies and guides appropriate interventions.

Collaborate with a registered dietitian to develop a personalized, balanced meal plan for Molly, taking into account her dietary preferences and restrictions. Rationale: A tailored meal plan can address Molly’s nutritional needs, promote weight loss, and reduce the risk of complications.

Educate Molly about healthy food choices, portion control, and the importance of regular meals to support weight management and improve overall nutrition. Rationale: Patient education empowers Molly to make informed decisions about her diet and encourages long-term lifestyle changes.

Nursing Diagnosis 2: Risk for Infection Interventions

Administer prescribed antibiotics as per the infectious disease specialist’s recommendations and monitor Molly’s response to the treatment. Rationale: Appropriate antibiotic therapy targets the identified infection and reduces the risk of its progression.

Promote meticulous hand hygiene among healthcare providers and educate Molly and her family about proper handwashing techniques (Mathur, 2011). Rationale: Effective hand hygiene minimizes the transmission of microorganisms and reduces the risk of healthcare-associated infections.

Monitor Molly’s vital signs, observe for signs of infection (e.g., fever, increased WBC count), and assess the surgical incision site or any wounds for signs of inflammation or purulent drainage (Loots et al., 2021). Rationale: Early detection of infection allows for timely interventions, such as wound care, initiation of appropriate antibiotic therapy, and prevention of complications.

Nursing Diagnosis 3: Impaired Tissue Integrity Interventions

Assess Molly’s skin for signs of pressure ulcers, particularly in areas prone to pressure, such as the sacrum, heels, and elbows. Rationale: Regular skin assessments help identify early signs of pressure damage, allowing for prompt interventions to prevent pressure ulcers.

Implement a turning schedule for Molly, ensuring she is repositioned at least every two hours, and utilize pressure-relieving devices as needed. Rationale: Frequent repositioning reduces pressure on vulnerable areas, improves tissue perfusion, and minimizes the risk of pressure ulcer development.

Educate Molly about the importance of maintaining adequate hydration and moisturizing her skin regularly to promote skin integrity. Rationale: Proper hydration and skin moisturization help maintain skin elasticity, reducing the risk of skin breakdown and promoting wound healing.

Conclusion

In caring for Molly McBurn, addressing her imbalanced nutrition, infection risk, and impaired tissue integrity are crucial. Through interventions such as monitoring dietary intake, collaborating with a dietitian, administering appropriate antibiotics, promoting hand hygiene, and implementing preventive measures for pressure ulcers, nurses can optimize Molly’s well-being, improve her health outcomes, and support her in making sustainable lifestyle changes.

References

Bailey, R. L. (2021). Overview of dietary assessment methods for measuring intakes of foods, beverages, and dietary supplements in research studies. Current Opinion in Biotechnology, 70, 91–96. https://doi.org/10.1016/j.copbio.2021.02.007 

Loots, F. J., Smulders, D., Giesen, P., Hopstaken, R. M., & Smits, M. (2021). Vital signs of the systemic inflammatory response syndrome in adult patients with acute infections presenting in out-of-hours primary care: A cross-sectional study. European Journal of General Practice, 27(1), 83–89. https://doi.org/10.1080/13814788.2021.1917544 

Mathur, P. (2011). Hand hygiene: Back to the basics of infection control. Hand Hygiene: Back to the Basics of Infection Control, 134(5), 611. https://doi.org/10.4103/0971-5916.90985