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

Patient info: Female, 68 years Pathophysiology: mass in right lower quadrant of the abdomen. Vital Signs and Labs Report: BP 108/60 P 110 R 20 T 98.8 F O2 sat 95% on 2L via nasal cannula

Priority 1 Nursing Diagnosis: Characterized by: Subjective Data: Vomiting, Nausea, Weakness, and weight loss Objective Data: Appears weak less intake

Goal: Patient expresses no weakness and nausea Outcome: Clients do not complain of nausea or vomiting Cheerful facial expressions. Vital signs within normal limits. Feeling strong again Nursing Interventions:1 Monitor food intake. R /: Adequate intake affects the healing process. 2 Provision of adequate calories and balanced meals. R /: Caloric intake helps the body in maintaining hemostasis. 3 Encourage clients to spend a portion of their food. R /: adequate intake can assist in the process of wound healing and helps in improving the general state of the client. 4 Encourage clients to eat small meals but often. R /: The food is more easily digested and can help intake is adequate. 5. Serve food in the form of interest and varies according to the client's nutritional needs. R /: Increase appetite to fulfill the nutritional needs of the client.

Evaluation: (Expected Outcome) A healthy person with good vitals and no trace of mass or any symptoms related to weakness

Patient Education with an explanation related to the patient’s health status and health promotion: I would recommend the patient to follow a good nutritious diet with good fiber and let her know that the mass is not always dangerous and can be removed easily. According to the National Cancer Institute, a mass is a lump in the body that can be caused by the abnormal growth of cells, a cyst, hormonal changes, or an immune reaction. Fortunately, a mass is not always cancer.