Nursing Report Mrs. Grace has had an uncomfortable night. Her pain…

Nursing Report Mrs. Grace has had an uncomfortable night. Her pain… Nursing Report• Mrs. Grace has had an uncomfortable night. Her pain has been from 6-8 on a scale of 0- 10. She has had minimal relief with morphine. The pain seems to be worse this morning.• Her husband has been with her tonight, and he is quite worried and frustrated. Mrs. Grace says her pain is in the upper abdomen with right side worse than left. The pain is intermittent and feels like bad labor pains. Her abdomen is distended and diffusely tender to palpation. Her abdomen seems more distended this morning. There are minimal, hypoactive bowel sounds present. The NG drained 600 mL dark brown green drainage this shift. Her urine output was 75 mL with dark yellow, thick urine.Client Background• Brittney Grace is a 35-year-old woman who was admitted to a• medical-surgical unit with a small bowel obstruction. She has• had a 4-day history of abdominal pain and vomiting, with up• to 12 vomiting episodes per day. The vomitus is blood• streaked at times. Her medical history includes an 8-year• history of hypertension and type 2 diabetes for 6 years.• Recent surgeries include an appendectomy 3 years ago.Biographical Data:• ¦ Age: 35• ¦ Gender: female• ¦ Height: 5 ft 8 in• ¦ Weight: 117 lbCultural Considerations• ¦ Language: English• ¦ Ethnicity: Hispanic• ¦ Nationality: American• ¦ Culture: no significant cultural considerations identifiedDemographic• ¦ Marital status: married• ¦ Educational level: community college• ¦ Religion: Episcopal• ¦ Occupation: administrative assistantCurrent Health Status• ¦ 4-day history of abdominal pain and vomiting, with up• to 12 vomiting episodes per day. The vomitus is blood• streaked at times.Allergies: Penicillin and Compazine Physician’s Orders• Vital signs: q 4 hr• Diet: NPO—may have occasional ice chips• Activity: up as tolerated with assistance• Assess for falls, and institute fall precautions• IV therapy: D5 0.45% NS with 20 mEq KCl/L @ 125 cc/hr• Diagnostic studies:o Blood sugar q 4 hr (bedside monitor)o CBC, electrolytes every morningo BUN, creatinine every morningo Flat and upright abdomen radiograph today• Medications:o Ciprofloxacin 400 mg IV q 12 hro Metronidazole 1200 mg IV infused over 1 hr for 1 dose and then 500 mg IV q 6hro Morphine sulfate 2 mg IV q 2-4 hr prn paino Acetaminophen 650 mg rectally q 4 hr prn temp >100.3oF.o Promethazine hydrochloride 10 mg IV q 4-6 hr as needed for vomiting or nausea o Lisinopril 20 mg per NG tube every dayo Regular insulin: sliding scale q 4 hr. Subcutaneous:? BG 70-150: give 0 units? BG 151-200: give 2 units? BG 201-250: give 4 units? BG 251-300: give 6 units? BG 301-350: give 8 units? BG <70 or >350: notify on-call physician______________________________________________________________COMPLETE THE FOLLOWING INFORMATION:1.After reviewing the client background and nursing report, you are ready to assess your client’s current status. Under each category, identify how you would target your assessment, and what you would expect to find for the patient with small bowel obstruction.Physical Exam • General appearance:• Integumentary:• HEENT:• Respiratory:• CV:• Abdominal:• Neuro:• Musculoskeletal:Additional Findings:•1 •2 •32. Considering the age of your client, are there any developmental issues you need to address?3. What diagnostic test results relevant to the patient’s current problem are needed to plan care? How are these tests significant to the patient problem.4.Identify 3 drugs that may be used to treat a patient with a small bowel obstruction and a nasogastric tube. List the Name of the Drug, Classification, Side Effects and Nursing Implications.SCENARIO CONTINUED:When you next visit Mrs. Grace’s room you find: 100.8°F; 92, regular, respirations 22, slightly shallow, BP 112/72. O2 sat = 96% RA. Patient vomiting & moaning in pain. NG tubing under pillow. Not hooked to suction. Pain 7/10 mid upper abdominal area. Constantly dull, intermittently sharp, non-radiating, increases with movement.1. Identify 3 Nursing Actions you would immediately take:…You found the NG tubing under pillow. Not hooked to suction. Pain 7/10 mid upper abdominal area. Constantly dull, intermittently sharp, non-radiating, increases with movement. Abdomen diffusely tender to palpationT 101.8°F, 128, R 30, BP 126/78 mm Hg , Faint bowel sounds. Weak, lethargic, disoriented. Capillary refill >5 sec. AM labs: Hgb 9.2; Hct 42%, K+ 2.8 mEq; 0.9% NS IV fluids are infusing.2. LIST 3 NURSING DIAGNOSIS’ WITH SMART GOALS AND INTERVENTIONS:1. Nursing Diagnosis:Smart Goal: (1 Short Term, 1 Long Term) Nursing Intervention:2. Nursing Diagnosis:Smart Goal: (1 Short Term, 1 Long Term)Nursing Intervention:3. Nursing Diagnosis:Smart Goal: (1 Short Term, 1 Long Term) Nursing Intervention:You return to the room, after gathering supplies, to find B/P 96/70, HR 123. Patient not oriented to place. Mucous membranes dry, poor skin turgor, cool, pale skin, minimal urine output.Provide SBAR to physician.S: B: A: R: Image transcription textSCENARIO CONTINUED: When you next visit Mrs. Grace’s room you find: 100.8 F; 92, regular, respirations 22,slightly shallow, BP 112/72. 02 sat = 96% RA. Patient vomiting & moaning in pain. NG tubing under pillow.Not hooked to suction. Pain 7/10 mid upper abdominal area. Constantly dull, intermittently sharp, … Show more… Show more Health Science Science Nursing NURS MISC Share QuestionEmailCopy link Comments (0)

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