lOMoARcPSD|60 70128
Cirrhosis
1.
2. Perfusion
3.
4.
5.
6.
7. Communication
8.
, lOMoARcPSD|60 70128
Cirrhosis
History of Present Problem:
John Richards is a 45 - year - old male who presents to the emergency department (ED) with abdominal pain and
worsening nausea and vomiting the past three days that have not resolved. He is feeling more fatigued and has
had a poor appetite the past month. He denies any ETOH (alcohol) intake the past week, but admits to episodic
binge drinking on most weekends.
John weighs 150 pounds (68.2 kg) and is 6'0" (BMI 17.6). You are the nurse responsible for his care.
Personal/Social History:
John is single, has never married, and lives alone in his own apartment. He has struggled with heroin
use/abuse in the past, but has not used in the past two years. John is currently unemployed and has no health
insurance. He was diagnosed with hepatitis C ten years ago but has had minimal follow - up medical care
since.
What data from the histories are RELEVANT and have clinical significance to the nurse?
RELEVANT Data from Present Problem: Clinical Significance:
Abdominal pain S/S cirrhosis
Nausea and vomiting Risk for hypovolemia/ F+E imbalance Fatigue poor Alcohol
can be a causative factor
appetite Malnutrition episodic binge drinking
BMI 17.6
RELEVANT Data from Social History: Clinical Significance:
Lives alone Possibly no support system
Unemployed Hep C - risk factor
Past Dx of Hep C.
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. Classification: Expected Outcome:
Cirrhosis
1.
2. Perfusion
3.
4.
5.
6.
7. Communication
8.
, lOMoARcPSD|60 70128
Cirrhosis
History of Present Problem:
John Richards is a 45 - year - old male who presents to the emergency department (ED) with abdominal pain and
worsening nausea and vomiting the past three days that have not resolved. He is feeling more fatigued and has
had a poor appetite the past month. He denies any ETOH (alcohol) intake the past week, but admits to episodic
binge drinking on most weekends.
John weighs 150 pounds (68.2 kg) and is 6'0" (BMI 17.6). You are the nurse responsible for his care.
Personal/Social History:
John is single, has never married, and lives alone in his own apartment. He has struggled with heroin
use/abuse in the past, but has not used in the past two years. John is currently unemployed and has no health
insurance. He was diagnosed with hepatitis C ten years ago but has had minimal follow - up medical care
since.
What data from the histories are RELEVANT and have clinical significance to the nurse?
RELEVANT Data from Present Problem: Clinical Significance:
Abdominal pain S/S cirrhosis
Nausea and vomiting Risk for hypovolemia/ F+E imbalance Fatigue poor Alcohol
can be a causative factor
appetite Malnutrition episodic binge drinking
BMI 17.6
RELEVANT Data from Social History: Clinical Significance:
Lives alone Possibly no support system
Unemployed Hep C - risk factor
Past Dx of Hep C.
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. Classification: Expected Outcome:
