Question

In: Nursing

You are the triage nurse in the Emergency Department. Your patient, Mr. Sawyer, is a 48...

You are the triage nurse in the Emergency Department. Your patient, Mr. Sawyer, is a 48 year old man who presents with severe abdominal pain, poor appetite, and fatigue. He states the pain awakened him from sleep and he began vomiting. He denies any relief from the pain and he can’t get comfortable as the pain radiates to his back and right shoulder. He rates his current pain level as 10/10. He denies any previous medical or surgical history. He denies any tobacco or drug use. States he drinks “just a beer or two after work each day” though he reports to “more than usual” alcohol consumption this past weekend after attending a bachelor party. He lives with his wife and 2 children and works fulltime as a construction foreman. Initial vital signs: BP 160/94, resp 24, pulse 100, temp 99.6 orally, pulse ox 99%.

Based on Mr. Sawyer’s chief complaint what additional physical exam techniques / tests would you want to include in your physical assessment of him? Be thorough & detailed in your description.

Solutions

Expert Solution

As per History:-
​Name: Mr. Sawyer
Age: 48yrs
​Gender: Male
Past history: not applicable
​Present history: He drinks just a beer or two after work each through he reports to more than usual, alcohol consumption this past weekened after attending a bachelor party.
​Family history: Lives with wife and 2childrens.
​Present Complaint: severe abdominal pain,poor appitite, fatigue,vomiting,pain radiating to his back and right shoulder.pain level 10/10
​Vital signs: BP 160/94, resp 24, pulse 100,temp 99.6 orally,pulse Ox 99%
​ As per mr.sawyer complaint first Assessment include as per triage nurse:-
---Make the patient comfortable with his position on bed.
​---Complete medical history collection
----Start continuous monitoring of patient(Vitals)
---Physical examination include pain assesssment where exactly pain by inspecting his four quadrants and where it is radiating
---Psychological support
​---Assess his hydration level because his vomiting
---As per doctors order admin anti- emitic drugs and narcotics according to his pain level..
​---Call for Gastroenterologist
​---call lab people for initial blood investigation(CBC,RBS,LFT,Serum enzymes, BUN Level
​---Once pain settle for the patient send patient for comlete USG(ultra sonogram)
​---Monitor his Blood pressure lever every 1/2 hour
​---follow the doctors orders accordingly...

Nightingale answered 2 years ago
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