Question

Case Scenario: “lapay”
Mr. Lopez, a 60 y/o teacher, presents with a history of a sudden onset of acute upper central abdominal pain radiating to his back. The nurse attending Mr. Lopez asked about how it started. He stated that “this morning after breakfast, I had sudden, severe pain in my abdomen and I vomited a couple of times, but the pain still persists. It hurts here, above my belly button, and feels like it goes
straight through to my back.”

On the client’s past medical history, he had an appendectomy at age 25 and tonsillectomy at 7. He was also diagnosed with hypertension 5 years ago and pre-diabetes 6 months ago. When asked about pertinent family history, he willingly disclosed that he had a sister, 45 yo, was diagnosed with cholelitihiasis 2 years ago, a brother who is 54 yo had a cholecysytectomy 5 years ago for acute
cholecystitis and cholelithiasis and mother who is 80 yo had also underwent cholecystectomy for acute cholecystitis and cholelithiasis 13 years ago.

Mr. Lopez admits to drinking whiskey most evenings but denied that he was never a smoker. The client also stated that he has no known allergies and currently taking Aspirin 325mg every day, Propranolol 30 mg every day and Hydrochlorthiazide 25 mg every day.

Upon PE, vital signs reveals a blood pressure of 110/60 mmHg, HR of 110 bpm, RR of 24 cpm, body temperature of 38.4 OC and a pain scale of 8 out of 10. Upon auscultation, no murmurs or extra cardiac sounds were noted, both lungs are clear and palpation of the abdomen, tender in the mid-epigastrium with guarding and rebound tenderness.

1. Develop a Nursing care plan (ADPIRE, Assessment, Diagnosis, Planning-short term and long term goal, Intervention-Rationale, Evaluation) for Mr. Lopez according to your identified priority plan of care.

Answer 1

Mr. LOpaz is 60 year old male admitted with the history of upper central abdominal pain and it radiates to back. He had sudden onset of pain after having food associated with vomiting.

He had history of appendectomy at age of 25 years old and tonsillectomy at age of 7. He has had hypertension and prediabetes for the last 5 years, 6 moths respectively. He has family history cholelithiasis and cholecystitis.

    On examination: his vital signs are blood pressure is 110/60 mm of HG, Temperature is 38.6 C, and pulse is 110 beats /minutes. Respiratory rate is 24beats/minute.

On palpation: he has rebound tenderness and tender in mid epigastrium.

Mr. lopaz has been suffered from acute cholecystitis and cholelithiasis

Nursing care plan

1. Acute pain related to due to obstruction to cystic duct as evidenced by verbal report, rebound tenderness

2. Hyperthermia related to inflammation as evidenced by temperature 38. 4 c

3. Fluid volume deficit related to vomiting as evidenced by avoidance of fluids

4. Imbalanced nutrition less than body requirement related to vomiting couple of times as evidenced by avoiding of food

5. Fatigue related to pain and vomiting as evidenced by the sad face and showing grimace

6. Anxiety related to sudden onset of pain as evidenced by increased heart rate and facial expression

7. Knowledge deficit related to disease and   management as evidenced by the familial disease

Assessment	Nursing diagnosis	planning short term and long term goal	Intervention	rationale	evaluation
Subjective data I have pain in the central abdomen Objective data: Rebound tenderness while palpation	Acute pain related to due to obstruction to cystic duct as evidenced by verbal report, rebound tenderness	To relieve his pain	. assess the pain by using scale and characteristics of pain Provide comfortable position Educate to do deep breathing exercises Instruct to use diversional therapy Monitor vital signs Administer analgesic as prescribed	It helps to plan baseline data It decreases intraabdominal pressure It helps to relax muscles It helps to divert mind from the pain Pain increase blood pressure Analgesic reduces his pain	His pain will be relieved
Subjective data I feel temperature in my body Objective data Temperature 38.6 C	Hyperthermia related to inflammation as evidenced by temperature 38. 4 c	To reduce his body temperature	. assess the vital signs Switch on the fan and open the window Advise to wear cotton clothes Provide tepid sponging Administer antipyretic as prescribed	It helps to assess his temperature It reduces temperature by convection and radiation It reduces heat by allowing air It reduces heat
Subjective data: I have vomited couple of times Objective data Aversion to fluid	Fluid volume deficit related to vomiting as evidenced by avoidance of fluids	To maintain fluid volume	Assess the fluid status of the patient Assess the electrolyte level of the patient Insert the nasogastric tube until vomiting resolves Monitor intake and output Start the liquid if he tolerates Administer intravenous fluid s	It helps to plan of care Derangement of electrolyte may decrease or increase blood pressure It helps to decompress the stomach and avoid electrolyte loss by vomiting It helps to measure positive or negative fluid status Starting a Liquid diet help to assess tolerance to fluids It helps to meet fluid status	His fluid volume will be maintained
Subjective data I have vomited couple of times Objective data Fear to have food because of vomiting	Imbalanced nutrition less than body requirement related to vomiting couple of times as evidenced by avoiding of food	To relieve vomiting	Assess the patient nutritional status Insert nasogastric tube for shorter period if he has vomiting and pain Advise to have mouth before having food Advise to do breathing exercises Provide low fat liquids if he tolerates Educate to consume high carbohydrate and high protein diet Administer intra venous fluids	It helps to assess and change the diet It decompress abdomen and decreases intra abdominal pain It gives freshness to him to consume food It helps to reduce pain and intake is increased High fat foods increases pain It provides energy and increases consumption It helps to meet fluid volume	His nutritional status will be maintained to normal
Subjective data : I have continuous pain Objective data : Showing grimace	Fatigue related to pain and vomiting as evidenced by the sad face and showing grimace	To reduce fatigue	Assess the fatigue status of the patient    Provide comfortable position Advise to take rest Provide comfortable devices such as pillow Provide small and frequent feed if he tolerates Advise him to reduce frequent activities	It helps to assess the fluid status It reduces fatigue and pain It conserves energy It helps to provide him comfort Food gives energy Activities increases pain	His fatigue will be reduced
Subjective data I have continuous pain and it hurts more Objective data He shows facial expression	Anxiety related to sudden onset of pain as evidenced by increased heart rate and facial expression	To relieve his anxiety	Assess the anxiety level of the patient Encourage too use relaxation therapy Explain the procedure in clear and concise manner Provide him quiet environment Show an example of his mother and brother	It helps to relieve pain It helps to divert mind It helps to relieve his fear It helps to reduce stimuli and reduces anxiety It helps to reduce and increases coping ability	His anxiety will be relieved