Jim Sanderson - 10.9.2020 latest case study graded A(2020/2021)

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. . abdomen is obese, rounded, firm and tender to palpation Good nutrition is necessary to keep the immune system strong to fight off infection. Abdominal tenderness is generally a sign of inflammation or other acute processes in one or more organs RELEVANT Data-Current Complaint: Clinical Significance: nausea Check to see if Zofran is available for patient wretch and has a small bile green emesis. Possibility of bile reflux. According to Mayo clinic Bile reflux can also 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 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 Current Assessment: GENERAL APPEARANCE: Patient’s body and facial expression appears tense, uncomfortable 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 be taken to verify results. worsened RELEVANT Assessment Data: Clinical Significance: Temp 99.2 Monitor temperature by continuous reassessment to check 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. n/a 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. 2. INTERPRETING relevant clinical data, what is the primary problem? What primary health related concept(s) does this problem represent? (Management of Care/Physiologic Adaptation) (Utilize pathophysiology book when considering disease processes) Problem: Pathophysiology of Problem in OWN Words: Primary Concept(s): Paralytic ileus This is basically when the muscles in the ileus lose its function of contracting. Obstruction of the intestine due to paralysis of the intestinal muscles. The paralysis does not need to be complete to cause ileus, but the intestinal muscles must be so inactive that it prevents the passage of food and leads to a functional blockage of the intestine. 3. What nursing priority(ies) will guide your plan of care that determines how you decide to RESPOND? (Management of Care) (List 2) Nursing Diagnosis: (based on primary problem) PRIORITY Nursing Interventions: (patient symptom specific) Rationale: Expected Outcome: Access patient The essential requirement of accurate assessment is to view patients holistically and thus identify their real needs Have accurate information on pt. vitals etc. Call the doctor Call the doctor giving him all the information he needs to make proper orders for patient Nurse will fulfill orders given by doctor to help patient.