Question

You are working as a nurse in the emergency department. The triage nurse walks a patient into one of your empty rooms. You look at the computer to see her name is Penny, 20-year old female, c/o abdominal pain. No known drug allergies, no current medications, and denies previous medical history.  

Assessment: Penny is awake, alert, and oriented x3. Reports lower abdominal pain x 2 days. Rates her pain a 6/10, but states it is sometimes a 10/10. +nausea, denies vomiting. Physical examination finds lungs clear bilaterally and heart sounds regular. +bowel sounds x 4 quadrants. Abdomen tender to palpation. Slightest touch causes her to wince with pain. During your physical examination, you notice bruises on her arms and back. Further questioning finds burning with urination. Last bowel movement was prior to arrival. She states frequent diarrhea d/t her use of laxatives as a way to lose weight. She is due to start her next menstrual cycle next week. VS: T-37.6   BP-102/54   HR-105 RR-22    Height 5’4” Weight 100 lbs.

Social history: Penny currently lives with her parents and attends school full-time at the local community college. She is still covered under her father’s insurance plan. +smokes 2-3 cigarettes/day and admits to marijuana use when someone offers her some. You ask her if she is sexually active and she tells you she started using dating apps about 3 months ago and she “has been having a lot of fun”. She reports many new dates over the last few weeks and “feels obligated” to go home with them after the date. You question her about unprotected sex and she admits “if the guy doesn’t use a condom, I don’t say anything about it”.

Pelvic exam: Pelvic examination reveals purulent material pooled in the vaginal vault, which appears to be coming from the cervix. The physician also notes red, friable cervical ectopy. There is also a distinct odor. The vaginal drainage is swabbed and sent to microbiology for culture. You prepare a wet mount for the physician to look for trichomoniasis.

   

Labs:

RBC:            3.5                                          K+:    3.0                         Urine preg:             Negative

WBC:           11.2                                       Na:    130                        UA:                 

HGB:            9                                             CL:     95                          Specific Gravity     1.030

HCT:             35                                          Mg:   1.6                          WBC                        8

Platelets:    130,000                                                                          Ketones                 trace

                                                                                                             pH                         

PATIENT TEACHING NEEDS (Teach care-giver if patient cannot be taught-include all areas of need)(Must include at LEAST 3 with specific detail)

1.

2.

3.

DIAGNOSTIC STUDIES –    normal     Significance for this Client – why specifically       What doe the results mean?                                                    value        was this lab done for your client                       (PATIENT                         VALUES)

CBC RBC WBC Hct Hgb Platelets

DIAGNOSTIC STUDIES –   normal     Significance for this Client – why specifically       What do the results mean?                                                    Value       was this lab done for your client                           (PATIENT                             VALUES)

Others:   X-Ray,                                                                            CT scan, MRI, EKG, etc. Electrolytes: K Na Cl Mg

DIAGNOSTIC STUDIES –                    (PATIENT                     VALUES)            normal     Significance for this Client – why specifically       What do the results mean?                                                   value         was this lab done for your client

Any other labs that pertain to client dx (ie. BNP, CO2, Digoxin)

PROBLEM LIST List all problems identified in the assessment	CONCEPT (i.e. Perfusion, Oxygenation, Mobility)	Choose four (4) priority problems for concept maps and state in nursing diagnosis format.
		1. 2. 3. 4.

CONCEPT MAP

Choose two (2) priority nursing diagnoses, of which one must be an actual problem. Expand on each one – including format, goal, and interventions. Goals must be measurable, short-term, and achievable within 48 hours. (Include medications, labs, diagnostic studies, etc).

Answer 1

- list all the problems are identified:

Lower abdominal pain

Nausea, denies vomiting

Bruises on her arms and back

Burning with urination

Frequent diarrhoea

Lack of knowledge in sex education

Red, friable cervical ectopy with distinct order

Nursing diagnosis: (as priority needs)

1. Acute abdominal pain related to inflammatory process.

2. Knowledge deficiency regarding sex education as evidence by patients behaviour and her expression.