Care Map Case Study

S.T. is a 40-year-old female weighing 120 lbs. and lives with her family in a single home. Today she is admitted complaining of left-sided severe abdominal pain which is relieved at the hospital with medications. She reports, “My pain level is much better! 2/10 now. It was 10/10.” S.T. states she has lost weight over the last two months. She was 160 lbs. S.T. says she makes herself eat but just isn’t hungry. Complains of being “tired all the time” and feels nauseous when she smells food. The morning tray is at the bedside an ¼ is eaten. Her stools are dark and soft. Urine output is 1500 mL/day clear yellow. Her vital signs are Heart Rate (HR) 88(high) regular Respiratory Rate (RR) 18 Blood pressure (Bp) 110/86 Temperature 99.6F(high) Oxygen saturation 99% Her family is at the bedside (husband, daughter (13), and son (11). They appear concerned but conversational. 

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Alex Otieno

Author Since: January 17, 2021

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