Peggy Scott is a 48-year old African American woman GI System assessment PDF

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Summary

Peggy Scott is a 48-year old African American woman who came to the emergency department because she is having severe abdominal pain radiating to the back that started 24 hours ago but has become progressively worse in the last couple of hours. She is now nauseated and states that she has “puked sma...

Description

Present Problem: Peggy Scott is a 48-year old African American woman who came to the emergency department because she is having severe abdominal pain radiating to the back that started 24 hours ago but has become progressively worse in the last couple of hours. She is now nauseated and states that she has “puked small amounts of green liquid” five times in the last four hours. She had two loose stools today that were dark brown or black in color. Peggy has struggled with ETOH use/abuse most of her adult life but has been sober the past six months. She begins to cry and tells the nurse that this week was the one-year anniversary of her only son’s death in an automobile accident. She reports that she has been drinking one liter of vodka daily the past week. What data from the present problem are RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential) RELEVANT Data from Present Clinical Significance: Problem: -Severe abdominal pain radiating to the -symptom of pancreatitis back -Nausea from alcohol intake which increases the production of -Nauseous stomach acids and Puked green liquid 5x delays the stomach from -Puked green liquid emptying also a sign of pancreatitis -Loose stool dark brown/black - Green/yellow vomit could indicate bile produced by the gallbladder -Crying about son’s death -Brown stool is normal but black would indicate bleeding in the GI -ETOH tract iron/ something she ate What is the RELATIONSHIP of your patient’s past medical history (PMH) and current meds? (Which medication treats which condition? Draw lines to connect.) PMH: Home Meds: Pharm. Class: Mechanism of Action (own words):  Ibuprofen 600  Depression -nonsteroidal -(NSAID) Inhibits COX-1, COX-2, Blocks mg PO three Inflammatory class arachidonate,  Low back pain Anti-inflammatory times daily PRN  Pancreatitis  Citalopram -Selective serotonin (no current meds) 40 mg PO reuptake inhibitors -Used for depression  ETOH abuse daily (no current meds) Patient Care Begins: Current VS: T: 100.6 F/38.1 C (oral) P: 98 (regular) R: 20 (regular) BP: 146/94 O2 sat: 95% room air

P-Q-R-S-T Pain Assessment: Provoking/Palliative Movement provokes, nothing relieves pain : Quality: Sharp Region/Radiation: Epigastric area/LUQ Severity: 10/10 Timing: Continuous since onset 24 hours ago

What vital signs are abnormal? What is the reason (pathophysiology) for these findings? (Reduction of Risk Potential/Health Promotion and Maintenance) Abnormal VS: Clinical Significance: -High fever likely caused due to pancreatitis T: 100.6 oral temp P: 98

-Although this is within normal limits it is borderline to tachycardia likely caused by pain level hypovolemia

R: 20 BP: 146/94

-Although this is technically normal it is borderline Tachypnea likely caused by current sitation, pain level -High BP could be a result of pain level and alcohol intake

Current Assessment: GENERAL SURVEY: NEUROLOGICAL: HEENT:

RESPIRATORY: CARDIAC:

ABDOMEN: GU: INTEGUMENTARY:

Alert, oriented, pleasant, in no acute distress, Is unkept in appearance with soiled clothing, body tense, grimacing Alert & oriented to person, place, time, and situation (x4) Head normocephalic with symmetry of all facial features. PERRLA, sclera white bilaterally, conjunctival sac pink bilaterally. Lips, tongue, and oral mucosa pink and tacky dry in appearance. Breath sounds clear with equal aeration on inspiration and expiration in all lobes anteriorly, posteriorly, and laterally, nonlabored respiratory effort on room air. Pink, warm & dry, no edema, heart sounds regular, pulses strong, equal with palpation at radial/pedal/post-tibial landmarks, brisk cap refill. Heart tones audible and regular, S1 and S2, noted over A-P-T-M cardiac landmarks with no abnormal beats or murmurs. No JVD noted at 30-45 degrees. Abdomen round, soft, and tender in epigastric area and LUQ to gentle palpation. Nauseated with small light bile green emesis, BS + in all four quadrants Voiding without difficulty, urine dark amber Skin warm, dry, intact, normal color for ethnicity. No clubbing of nails, cap refill...