Question

Chief Complaint: Nausea, vomiting, progressive weakness, and weight loss

History of Present Illness: 68-year-old female presented to Emergency Department with nausea and vomiting for several days following weeks of poor appetite and increasing weakness. Patient is dehydrated and complains of generalized abdominal pain. CT of abdomen shows mass in right lower quadrant of abdomen.

Allergies: Sensitivity to penicillin and cephalosporins

Past Medical History: Patient has a history of rectal polyps, atrial fibrillation for the past 8 years and severe osteoarthritis for the past 20 years.

Surgical History: Arthroscopic knee surgery approximately 20 years ago for right knee pain. Patient states she had Meperidine for postop pain control at that time. Requests Meperidine at this time for pain management.

Gyn History: Postmenopausal for approximately 18 years

OB History: Gravida 3, para 2, has two healthy adult children. Had one miscarriage at about 6 weeks gestation.

Social History: Born in Thailand. Married American GI and moved to the United States. Patient is primary caregiver for her 84-year-old mother. Patient is college educated in the U.S., but the language used at home is primarily Thai. Patient denies smoking or alcohol use. Patient denies illicit drug use.

Family History: Father died at age 70 from colon cancer. Sister, age 66, is currently being treated for ovarian cancer. Mother has debilitating arthritis and scoliosis, but is otherwise healthy.

Medications: Home medications include Digoxin 0.125 mg daily, Warfarin 5 mg daily, Celecoxib 200 mg every 12 hours. Specifically requests Meperidine for pain control.

Review of Systems: HEENT: Denies headaches, vertigo, syncope, changes in vision or hearing. No problems with chewing or swallowing. Cardiovascular system: Denies chest pain or palpitations. Patient states she has had A-fib for a number of years. Denies problems with circulation. Respiratory system: No shortness of breath or pain with breathing. Denies cough. No recent colds. Gastrointestinal system: Reports ribbon-like stools and blood in stools recently--has not been able to have BM for last several days. C/O nausea, pain, and decreased appetite. Musculoskeletal system: Complains of joint pain in knees--states she has arthritis. Sometimes this makes ambulation difficult. No other complaints.

Physical Exam: GENERAL: Well-developed 68-year-old Asian female

VITAL SIGNS: BP 108/60 P 110 R 20 T 98.8 F O2 sat 95% on 2L via nasal cannula

HEENT: Normal, pupils round, reactive to light. No lymph nodes palpable.

LUNGS: Breath sounds are clear, somewhat diminished in the bases. Patient is somewhat tachypneic due to abdominal pain. Equal expansion, patient denies cough.

HEART: Irregular rhythm, S1 S2, no S3, no murmurs, clicks or rubs. Pulses 1+, no edema or jugular venous distention. Digoxin level of 2.1 on admission labs.

ABDOMEN: Abdomen firm and distended. Patient complains of generalized tenderness and pain with palpation. Bowel sounds are hyperactive.

EXTREMITIES: Moves all extremities. Scar noted right knee status post arthroscopy. Some joint deformity noted in hands.

SKIN: Intact, no redness or bruising noted

BACK: Negative assessment except for slight stooping of the shoulders

GENITALIA: External genitalia normal

NEUROLOGIC: Awake, alert, no neurologic deficits noted. Cranial nerves I-XII intact.

Impression: 68-year-old female in moderate distress due to bowel obstruction, possibly secondary to abdominal mass.

Plan: 1. Decompress abdomen. 2. Correct electrolyte imbalance. 3. Reverse anticoagulation. 4. Surgical removal of abdominal mass.

question

Medical Surgical Nursing Clinical – Concept Map

Patient info: Vital Signs and Labs Report:

Pathophysiology:

Priority 1 Nursing Diagnosis:

Goal: Outcome:

Nursing Interventions:

Evaluation: (Expected Outcome)

Patient Education with explanation related to the patient’s health status and health promotion: (Please list in bullet points, type your answers in black fonts):

References:

Answer 1

Medical surgical Nursing Clinical -concept map

Patient info: . Name:xxxx . Age:68 years . Sex: female .Place:United States Vital Signs and Labs Report: Blood pressure:108/60 Pulse  rate:110 Respiratory rate;20 Temperature : 98.8F O2 saturation:95% Lungs ; sound are clear,shows tachypnea.equal expansion. Heart:Irregular rhythm in S1,S2 not S3. No edema ,pulse1+ Abdomen: Firm and distended.Bowel sound are hyperactive. Neurologic: Cranial nerve I - XII are intact.

Pathophysiology: Abdominal pain is caused by the intestinal obstruction and this is due the blockage in intestine lead to impairment of the passage of material through the bowel which results in distension of proximal intestine.This can results in necrosis and perforation of bowel and lead to local and systemic inflammatory response activation and translocation of bacteria through the wall of intestine.

  

Priority 1 Nursing Diagnosis: Fluid volume is reduced because of the decrease in intestinal fluid absorption and loss of fluid secondary to vomiting. Diagnosed with Intestinal obstruction having nausea,vomiting,progressive weaness,weightloss followed with poor appetite and increasing the weaness.Shows mass in right lower quadrant of abdomen.By examining shows generalised tenderness and pain with palpation.Bowel sounds are hyperactive.The patient have a medical history of rectal polyps,atrial fibrillation for past 10 years and severe osteoarthritis for the past 20 years.

Goal: Bowel decompression through a nasogastric tube Administration of intravenous fluids Bowel should be rest with nothing to eat. The elecrolyte imbalance could be corrected. Reverse anticoagulation surgical removal of abdominal mass. Outcome: Correction of metabolic derangement.Maintaing the function of nasogastric tube,measuring the nasogastric output,monitoring the nutritional status and assessing the improvement of return of normal bowel sounds,improvement in  abdominal pain and tenderness.

Nursing Interventions:Provide rappot with patient .Encourage the patient to tell the feeling about pain. .Observe or monitor the sign of dehydration and electrolyte imbalance . Fluid should be administered as order. ..   . Allow the patient to have relaxation technique suchas deep breathing.provide rest period.   . encourage the patient to do recreational activities like watching      .Move the patient slowly and deliberately. . Observe the severity and document it and look after the character of pain if it is steady,intermittent,colicky .

Evaluation: (Expected Outcome) Fluid volume will be  maintained. Patient Education with explanation related to the patient’s health status and health promotion: Explain about the labortory results and responsities of the nurse . Discuss the medical  and nursing management for the intestinl obstruction List about the medication and treatment given for the disease. Plan appropriate nursing intervention for intestinal observation Discuss about the discharge planning of the patient.