Case Study 3: Client Name – Jane Smith Complex Issues
Nurses’ Notes Vital S Lab Tests 1455: Presented to the ED with report of increasing epigastric pain throughout the day. Pain started after dinner last night and usual medication did not help. States has been treated for gastroesophageal reflux disorder (GERD) for over 5 years with a variety of drugs, most recently omeprazole 40 mg orally twice a day. Other medications include: Ibuprofen 800 mg orally every morning for osteoarthritis Amlodipine 10 mg orally every day for hypertension MVI 1 tab every day for general health Famotidine 20 mg orally before meals PRN 1530: While waiting to be examined by the physician assistant, client vomited 175 ml coffee-ground emesis. States feeling “a little dizzy.” HR increased to 94 BPM, BP 128/78 lying down and 112/62 sitting. Stat blood work drawn. 1610: Labs within normal range. H&H tomorrow AM at 0600. ECG shows normal sinus rhythm. Vomited 100 mL coffee-ground emesis. The nurse compares the current client findings to the previous findings in the ED nurses’ notes. Select which current client findings indicate that the client is improving or not improving. Client Finding Improving Not Improving Reports no vomiting since the client’s hospital stay almost 2 weeks ago Has only had occasional “stomach” pain after eating food containing onions Continues to take ibuprofen every day for osteoarthritis pain HR 80 BPM BP 156/90 A: Improving: Reports no vomiting since the client’s hospital stay almost 2 weeks O ago. Has only had occasional “stomach” pain after eating food containing onions. HR 80 BPM, BP 156/90 Not Improving: Continues to take ibuprofen every day for osteoarthritis pain. B: Improving: Reports no vomiting since the client’s hospital stay almost 2 weeks O ago. Continues to take ibuprofen every day for osteoarthritis pain. Not Improving: Has only had occasional “stomach” pain after eating food containing onions. HR 80 BPM, BP 156/90 C: Improving: Reports no vomiting since the client’s hospital stay almost 2 weeks O ago. HR 80 BPM Not Improving: Has only had occasional “stomach” pain after eating food containing onions. Continues to take ibuprofen every day for osteoarthritis pain, BP 156/90 D: Improving: Reports no vomiting since the client’s hospital stay almost 2 weeks ago. Has only had occasional “stomach” pain after eating food containing onions. HR 80 BPM, BP 156/90. Not Improving: Continues to take ibuprofen every day for osteoarthritis pain. E: Improving: Reports no vomiting since the client’s hospital stay almost 2 weeks ago. Has only had occasional “stomach” pain after eating food containing onions. HR 80 BPM Not Improving: Continues to take ibuprofen every day for osteoarthritis pain, BP 156/90
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