Question

T.B. is a 65-year-old retiree who is admitted to your unit from the emergency department (ED). On arrival, you note that he is trembling and nearly doubled over with severe abdominal pain. T.B. indicates that he has severe pain in the right upper quadrant (RUQ) of his abdomen that radiates through to his mid-back as a deep, sharp, boring pain. He is more comfortable walking or sitting bent forward rather than lying flat in bed. He admits to having had several similar bouts of abdominal pain in the last month, but “none as bad as this.” He feels nauseated but has not vomited, although he did vomit a week ago with a similar episode. T.B.experienced an acute onset of pain after eating fish and chips at a fast-food restaurant earlier today. He is not happy to be in the hospital and is grumpy that his daughter insisted on taking him to the ED for evaluation. After orienting him to the room, you perform your physical assessment. The findings are as follows: He is awake, alert, and oriented 3, and he moves all extremities well. He is restless, is constantly shifting his position, and complains of fatigue. Breath sounds are clear to auscultation. Heart sounds are clear and crisp, with no murmur or rub noted and with a regular rate and rhythm. Abdomen is flat, slightly rigid, and very tender to palpation throughout, especially in the RUQ; bowel sounds are present. He reports having light-colored stools for 1 week. The patient voids dark amber urine but denies dysuria. Skin and sclera are jaundiced. Admission vital signs are BP 164/100, pulse of 132 beats/min, respiration 26 breaths/min, temperature of 100 ° F (37.8 ° C), Sp O 2 96% on 2 L of oxygen by nasal cannula.

Diagnostic statement:

Goal: Interventions

1. 2. 3,

Answer 1

The nursing diagnosis are,

• Ineffective air way clearance related to thick ,viscousor bloody secreations,
• Risk for impared gas exchage related to decrease in effective lung surface
• Risk for infection related to inadequate primary defence and lowere resistance
• Imbalanced nutrition less than body requirement
• knwledge deficit related to the disease condition
• Anxity related to the complication and progress of the treatment

Nursing interventioins are,

1. Assess the respitatory function,rate,Rhythm,depth,breath sound
2. Assess the ability to expectorate the mucus cough effectively
3. Do the suctioning and clear the oral cavity if secreation present in the oral cavity
4. placce the patient in a semi or high fowlers position
5. maintain fluid intake

• Review the pathology of the disease
• iidentify the other risk like infeciton to the close relatives and friend
• Intrut the patient to spit in to a closed container
• Apply necessory infection control,put the patient in a respiratory isolation by mask
• identiify the individual risk factors

1. Assess the level of dysspnea
2. Evaluate the change in level of mentation
3. Encorage pursed lip breathing
4. Promot bed rest or limiit activity
5. Monitor by pulse oxymetry and ABG,if neccessory administer oxygen

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