Mr. Smith is a 71 year old male who presents with anorexia, nauseaand vomiting. No stool for 5 days
Mr. Smith is a 71 year old male who presents with anorexia, nauseaand vomiting. No stool for 5 days. Symptoms are described as beginning several days ago, and patient reports symptoms have been worsening since that time. Patient states abdominal pain 5/10 especially after eating. Past medical history is significant for DM type 2 (controlled with oral meds, diet, and exercise), depression, and history of gastric ulcer. Objective: VS: Temp 101oF, BP 95/60, HR 94, RR 20, SpO2 93% on 2L/min by NC. Admit weight: 218 lbs. Exam: General: A&Ox3, appears somewhat uncomfortable. HEENT: PERRLA, conjunctiva pink, sclera icteric, oropharynx mildly erythematous Neck: Supple, no adenopathy Lungs: clear, decreased sounds in all lobesHeart: regular rhythm, no murmurs, or gallops Abdomen: rigid, tender, hypoactive bowel soundsExtremities: 2+ pulses, trace edema in ankles, no rashes noted Neuro: unsteady gait, normal speech, sensations to light touch throughout CT scan: loops of dilated bowel and bowel obstruction Medical Diagnosis: intestinal obstruction Physicians Orders: 11/09/20 @ 0630 ??Place NG Tube to Low Intermittent Suction??Make NPO ??May be clamped for ambulation if tolerated ??Reglan 10 mg IV q 6 hours ??Compazine 10 mg PR q 6 hours PRN nausea/vomiting Nursing: For your patient with an NG tube and a bowel obstruction: List 2 high priority nursing diagnoses/patient problems (can be at risk for):1. 2. Create a SOAP note for your patient S O A P Health Science Science Nursing NS A335 Share QuestionEmailCopy link Comments (0)
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