Student-GI-GU Assessment n Reasoning questions and answers PDF

Preview

Summary

GI/GU:
Inspection: skin (coloration, vascularity, striae, scars, lesions, rashes)
• Contour – (flat, rounded, scaphoid, protuberant/distended)
• Umbilicus – contour
• Symmetry (relaxed, supine position)
• Abdominal movement during breathing
• Aortic pulsations

Description

Assessment & Reasoning GI/GU System

Jenna Simpson, 24 years old

Suggested GI/GU Nursing Assessment Skills to Be Demonstrated: GI/GU: Inspection: skin (coloration, vascularity, striae, scars, lesions, rashes) • Contour – (flat, rounded, scaphoid, protuberant/distended) • Umbilicus – contour • Symmetry (relaxed, supine position) • Abdominal movement during breathing • Aortic pulsations Auscultation: (completed before palpation/percussion to not alter bowel sounds) • Bowel sounds – 1 minute per quadrant up to 5 minutes with the diaphragm • Intensity, pitch, frequency • Vascular sounds – listen for bruits with bell. Percussion: • Percuss for tone in a systematic fashion to all quadrants • Percuss liver span • Dull percussion to liver and kidney (costovertebral angle – 12th rib) • Tympany to other parts of the abdomen Palpation: • Light palpation to all quadrants – 1 to 2 cm to detect tenderness • Deep palpation to all quadrants – 5 to 6 cm for masses (location, size, shape, pulsatility, mobility, tenderness) • Palpate bladder- light palpation ONLY; you only want to assess to see if it is distended • Palpate liver • Palpate spleen • Palpate kidneys

Make Learning Active! • • •

Role play or go through the interview/body assessment process – student to student or as a group. Review the case study as an application exercise in small groups or together as a class. Depending on your program, some content in the case study may not have been taught. Do not let that prevent you from utilizing this case study! Use it to promote learning by having students identify what they do not yet know and guide where they can find the information in the textbook or on the internet to address knowledge gaps. This is educational best practice and another way to scaffold knowledge!

© 2019 Keith Rischer/www.KeithRN.com

Present Problem: Jenna Simpson is a 24-year-old Caucasian female who weighs 210 pounds (95.5 kg-BMI of 36.5) who presents to the emergency department with sudden onset of sharp pain in the right side of her lower back that radiates to the right side of her abdomen and into her groin. The pain started ten hours ago, but lasted only 15 minutes and then went away. She took ibuprofen 600 mg PO an hour ago but has not helped, and the pain persists. She states that this pain is different than when she has epigastric pain because of gastroesophageal reflux disease (GERD). She feels nauseated but has not vomited. Jenna appears uncomfortable and pleads with the triage nurse, “Please do something to get rid of this pain! What is wrong with me?” 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 Problem:

Clinical Significance:

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): Anxiety Alprazolam 0.5 mg PO every 8 hours PRN Gastroesophageal reflux disease (GERD)

Pantoprazole 10 mg PO BID

Jenna is quickly brought to a room. You are the nurse and quickly collect the following assessment data:

Patient Care Begins: Current VS: T: 98.9 F/ 37.2 C (oral) P: 92 (regular) R: 28 (regular) BP: 148/84 O2 sat: 99% room air

P-Q-R-S-T Pain Assessment: Provoking/Palliative: Nothing changes the level of pain Sharp, severe Quality: Right back/flank that radiates into RLQ and groin Region/Radiation: 10/10 Severity: Constant the past hour Timing:

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:

© 2019 Keith Rischer/www.KeithRN.com

Current Assessment: GENERAL Obese female is sitting upright in bed. Alert, oriented, pleasant, in moderate distress, dress APPEARANCE: appropriate for the season, hygiene and grooming normal for age and gender, anxious, body tense, + grimacing, appears to be uncomfortable. RESP: Breath sounds clear on inspiration and expiration in all lobes anteriorly, posteriorly, and laterally, with equal aeration bilaterally ant/post, nonlabored respiratory effort with + tachypneic. Posture erect, sitting in bed, in moderate distress, on room air, AP diameter 1:2, symmetry of the thoracic cavity noted with inspiration and expiration CARDIAC: Pink, warm & dry, no edema, heart sounds regular with no abnormal beats, pulses strong, equal with palpation at radial/pedal/post-tibial landmarks, brisk cap refill, carotid pulse 3+ and regular bilaterally. Heart tones audible and regular, S1 and S2, noted over the 5 cardiac landmarks with no abnormal beats or murmurs. No JVD noted at 30-45 degrees. NEURO: Alert & oriented to person, place, time, and situation (x4); muscle strength 5/5 in both upper and lower extremities bilaterally. GI: Abdomen flat, soft, bowel sounds audible per auscultation in all four quadrants, nontender to gentle palpation in all four quadrants GU: Voiding without difficulty, dark amber/rusty color with recent void to collect urine specimen INTEGUMENTARY: Skin warm, dry, intact, normal color for ethnicity. No clubbing of nails, cap refill 100

WBCs 2

Bacteria None

Epithelial None

What lab results are RELEVANT and must be recognized as clinically significant by the nurse? (Reduction of Risk Potential/Physiologic Adaptation)

RELEVANT Lab(s):

Current:

Clinical Significance:

WBC 10.2

RELEVANT Lab(s):

Complete Blood Count (CBC) HGB PLTs 14.2 285

% Neuts 72

Bands 0

Clinical Significance:

Evaluation: Thirty Minutes Later… Evaluate the response to nursing and medical interventions. All orders have been implemented. What would be the EXPECTED response in clinical data collected if her pain and anxiety are decreased? Current VS: T: P: R: BP: O2 sat:

Most Recent: T: 98.9 F/ 37.2 C (oral) P: 92 (regular) R: 28 (regular) BP: 148/84 O2 sat: 99% room air

© 2019 Keith Rischer/www.KeithRN.com

Current PQRST: Provoking/Palliative: Quality: Region/Radiation: Severity: Timing:

Current Assessment: GENERAL APPEARANCE: RESP: CARDIAC: NEURO: GI:

GU:

INTEGUMENTARY:

1.

What data is RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential/Health Promotion and Maintenance)

RELEVANT VS Data:

Clinical Significance:

TREND: Improve/Worsening/Stable:

RELEVANT Assessment Data:

Clinical Significance:

TREND: Improve/Worsening/Stable:

2. Has the status improved or not as expected to this point? Does your nursing priority or plan of care need to be modified after this evaluation assessment? (Management of Care, Physiological Adaptation)

Evaluation of Current Status:

Modifications to Current Plan of Care:

3. What did you learn that you can apply to future patients in your care? Reflect on your current strengths and weaknesses this case study identified. What is your plan to make any weakness a future strength?

What Did You Learn?

What did you do well in this case study?

What could have been done better?

What is your plan to make any weakness a future strength?

© 2019 Keith Rischer/www.KeithRN.com...