Jim Sanderson is a 65-year-old male
History of Present Problem:
Jim Sanderson is a 65-year-old male who is admitted for acute lower abdominal pain which was the result of a ruptured
appendix. He had an open appendectomy and is now post-operative day three. He refuses to use the incentive spirometer or
get up in the chair and requires encouragement to get out of bed and ambulate on the unit. His appetite is poor, and he eats
a small portion of his meals but tolerates and drinks fluids readily. He has had 2200 mL intake to 1800 mL urine output the
past 24 hours. He denies nausea and has not had a bowel movement since surgery despite receiving milk of magnesia and
senna tabs daily. His abdomen is obese, rounded, firm and tender to palpation with hypoactive bowel sounds. His incision
site in his RLQ has no drainage. Swelling and mild erythema noted along the edge of the incision.
Current Complaint:
Jim puts on his call light. When you arrive, he states he feels nauseated. He has an order for ondansetron 4 mg IV every 4
hours PRN for nausea, and this is administered. Thirty minutes later he puts his call light on again, stating that his nausea
has gotten worse. While in the room, he begins to wretch and has a small bile green emesis.
What PRIORITY data from the story and current complaint do you NOTICE as RELEVANT and why is it clinically
significant? (Reduction of Risk Potential/Health Promotion and Maintenance) (list 2 for each section)
RELEVANT Data-Present Problem: Clinical Significance:
Refuses to use incentive spirometer After abdominal surgery, the breathing
pattern can change and result in various pulmonary complications.
Incentive spirometry is beneficial for patients affected in this way as it
promotes deep breaths, which will aid their recovery.
His appetite is poor. Good nutrition is necessary to keep the
immune system strong to fight off infection.
. abdomen is obese, rounded, firm and Abdominal tenderness is generally a sign of inflammation or other
tender to palpation acute processes in one or more organs
RELEVANT Data-Current Complaint: Clinical Significance:
nausea Check to see if Zofran is available for patient
Possibility of bile reflux. According to Mayo clinic Bile reflux can also
wretch and has a small bile green emesis. be a side effect of surgeries to the gallbladder or gastrointestinal tract
or can be caused by peptic ulcers blocking the pyloric valve. Intestinal
activity has slowed down.
Nursing Assessment Begins:
Current VS: Most Recent VS: Current WILDA:
T: 99.2 F/37.3 C (oral) T: 99.4 F/37.4 C (oral) Words: ache/cramp
1
, Jim Sanderson is a 65-year-old male
P: 92 (reg) P: 74 (reg) Intensity: 5/10
R: 24 (reg) R: 18 (reg) Location: generalized abdomen
BP: 168/88 BP: 142/80 Duration: ongoing-started last hour
O2 sat: 93% room air O2 sat: 98% room air Aggravate: movement
Alleviate: rest
2
, Jim Sanderson is a 65-year-old male
Current Assessment:
GENERAL Patient’s body and facial expression appears tense, uncomfortable
APPEARANCE:
RESP: Breath sounds clear with equal aeration bilaterally, diminished in the bases bilaterally,
nonlabored respiratory effort
CARDIAC: Skin color is pink, warm & dry, no edema, heart sounds strong, regular with no abnormal
beats, pulses 3+, equal with palpation at radial/pedal/post-tibial landmarks
NEURO: Alert & oriented to person, place, time, and situation (x4)
GI: Abdomen firm-tender to palpation, distended, with rare, high pitched tympanic bowel
sounds
GU: Voiding without difficulty, urine clear/yellow
SKIN: Skin integrity intact, abdomen incision edges intact with mild erythema along edges, staples
intact
What clinical data do you NOTICE that is RELEVANT and why is it clinically significant?
(Reduction of Risk Potential/Health Promotion and Maintenance)
RELEVANT VS Data: Clinical Significance: TREND:
Improve/Worsening/Stable:
Blood pressure is 168/88 High b/p showing pain need for manual blood pressure to worsened
be taken to verify results.
RELEVANT Assessment Clinical Significance:
Data:
Monitor temperature by continuous reassessment to check n/a
Temp 99.2 to make sure the low-grade fever is caught before it becomes
a real fever even though it decreased from 99.4 continue to
monitor patient to see if decrease in temperature will
continue. This could be a possibility of sepsis.
1. What additional clinical data would you need to collect to identify the primary problem to guide your plan of care?
(Management of Care) (think along the lines of laboratory testing or imaging to consider)
Abdominal CT scan or blood work such as CBC for infection.
3
History of Present Problem:
Jim Sanderson is a 65-year-old male who is admitted for acute lower abdominal pain which was the result of a ruptured
appendix. He had an open appendectomy and is now post-operative day three. He refuses to use the incentive spirometer or
get up in the chair and requires encouragement to get out of bed and ambulate on the unit. His appetite is poor, and he eats
a small portion of his meals but tolerates and drinks fluids readily. He has had 2200 mL intake to 1800 mL urine output the
past 24 hours. He denies nausea and has not had a bowel movement since surgery despite receiving milk of magnesia and
senna tabs daily. His abdomen is obese, rounded, firm and tender to palpation with hypoactive bowel sounds. His incision
site in his RLQ has no drainage. Swelling and mild erythema noted along the edge of the incision.
Current Complaint:
Jim puts on his call light. When you arrive, he states he feels nauseated. He has an order for ondansetron 4 mg IV every 4
hours PRN for nausea, and this is administered. Thirty minutes later he puts his call light on again, stating that his nausea
has gotten worse. While in the room, he begins to wretch and has a small bile green emesis.
What PRIORITY data from the story and current complaint do you NOTICE as RELEVANT and why is it clinically
significant? (Reduction of Risk Potential/Health Promotion and Maintenance) (list 2 for each section)
RELEVANT Data-Present Problem: Clinical Significance:
Refuses to use incentive spirometer After abdominal surgery, the breathing
pattern can change and result in various pulmonary complications.
Incentive spirometry is beneficial for patients affected in this way as it
promotes deep breaths, which will aid their recovery.
His appetite is poor. Good nutrition is necessary to keep the
immune system strong to fight off infection.
. abdomen is obese, rounded, firm and Abdominal tenderness is generally a sign of inflammation or other
tender to palpation acute processes in one or more organs
RELEVANT Data-Current Complaint: Clinical Significance:
nausea Check to see if Zofran is available for patient
Possibility of bile reflux. According to Mayo clinic Bile reflux can also
wretch and has a small bile green emesis. be a side effect of surgeries to the gallbladder or gastrointestinal tract
or can be caused by peptic ulcers blocking the pyloric valve. Intestinal
activity has slowed down.
Nursing Assessment Begins:
Current VS: Most Recent VS: Current WILDA:
T: 99.2 F/37.3 C (oral) T: 99.4 F/37.4 C (oral) Words: ache/cramp
1
, Jim Sanderson is a 65-year-old male
P: 92 (reg) P: 74 (reg) Intensity: 5/10
R: 24 (reg) R: 18 (reg) Location: generalized abdomen
BP: 168/88 BP: 142/80 Duration: ongoing-started last hour
O2 sat: 93% room air O2 sat: 98% room air Aggravate: movement
Alleviate: rest
2
, Jim Sanderson is a 65-year-old male
Current Assessment:
GENERAL Patient’s body and facial expression appears tense, uncomfortable
APPEARANCE:
RESP: Breath sounds clear with equal aeration bilaterally, diminished in the bases bilaterally,
nonlabored respiratory effort
CARDIAC: Skin color is pink, warm & dry, no edema, heart sounds strong, regular with no abnormal
beats, pulses 3+, equal with palpation at radial/pedal/post-tibial landmarks
NEURO: Alert & oriented to person, place, time, and situation (x4)
GI: Abdomen firm-tender to palpation, distended, with rare, high pitched tympanic bowel
sounds
GU: Voiding without difficulty, urine clear/yellow
SKIN: Skin integrity intact, abdomen incision edges intact with mild erythema along edges, staples
intact
What clinical data do you NOTICE that is RELEVANT and why is it clinically significant?
(Reduction of Risk Potential/Health Promotion and Maintenance)
RELEVANT VS Data: Clinical Significance: TREND:
Improve/Worsening/Stable:
Blood pressure is 168/88 High b/p showing pain need for manual blood pressure to worsened
be taken to verify results.
RELEVANT Assessment Clinical Significance:
Data:
Monitor temperature by continuous reassessment to check n/a
Temp 99.2 to make sure the low-grade fever is caught before it becomes
a real fever even though it decreased from 99.4 continue to
monitor patient to see if decrease in temperature will
continue. This could be a possibility of sepsis.
1. What additional clinical data would you need to collect to identify the primary problem to guide your plan of care?
(Management of Care) (think along the lines of laboratory testing or imaging to consider)
Abdominal CT scan or blood work such as CBC for infection.
3
