Question

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 describe your physical assessment. Be thorough & detailed in your answer.

Answer 1

Assessment points:

-Significant to take a satisfactory account of patients with severe abdominal discomfort.

-Built-up queries will permit the patient to narrate the arrangement of indications and harshness.

-Postponement in preliminary fluid therapy could reason organs to be injured.

-Satisfactory fluid recovery will advance the patient’s symptoms.

Nursing Consequences:

-Patient’s urinary production will preserve at smallest 32 cc/hr.

-Patient will be capable to endure clear fluids deprived of vomiting inside 24 hours.

-Patient will consume equal consumption and productivity in 24 hours.

-Patient’s electrolyte stages will continue within standard variety through hospital vacation.

-Patient will amount discomfort fewer than 3 on 1-10 gauge inside 6 hours.

-Patient will account feeling more sluggish within 48 hours.

Nursing Intercessions:

-The nurse resolve amount the patient’s urinary production each 2 hours.

-The nurse will degree the patient’s consumption and production each 12 hours.

-The nurse will gather blood through venipuncture for electrolyte levels apiece doctor instructions.

-The nurse will display the patient’s psychological position every 2 hours.

-The nurse will measure patient’s willingness for strong fluids within 4 hours.

-The nurse will measure patient’s discomfort assessment each 4 hours.

-The nurse will manage 1 mg IV Morphine drug each 4 hours as wanted for discomfort superior as 7 on 1-10 gauge as well-ordered by the doctor.

-The nurse will measure the patient vigor level each alteration.