Chief Complaint: Diffuse abdominal pain, nausea, vomiting, and diarrhea Situation: Mr. C a 70 – ye
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Chief Complaint: Diffuse abdominal pain, nausea, vomiting, and diarrhea
Situation:
Mr. C a 70 – year old, male, presents to the emergency department with a complaint of severe nausea, vomiting, and diarrhea. He also notes diffuse abdominal pain, described as “twisting and cramping.” Upon further interview, Mr. C notes that he and his wife (who is at the bedside) have just come back from a cruise to the Bahamas, for their 50th wedding anniversary. When their ship made port, he began to feel cramping in his abdomen. Shortly after that, he states, “I was running to the bathroom.” He continues to say that initially, he felt nauseous and thought it was just “sea-sickness,” However, he knew something was wrong when he felt increasing nauseousness and began to vomit. His wife attempted to give him ginger ale to soothe his stomach, but only increased his nausea, which then led to more vomiting. He goes on to state, “When we got home, that’s when the bottom part started to act up.” Mr. C describes multiple episodes of diarrhea, described as “yellow and watery.” He began to feel weak and as his wife describes, “could not get up off the toilet.” That is when she called 911 and brought her husband in to be seen.
Background
Medical History
Surgical History
Psychosocial History
Hypertension
Hypercholesterolemia
Erectile dysfunction
Osteoarthritis
Right hip fracture (fall)
Right hip replacement
PTSD
Medications Taken at Home
Amlodipine 10mg PO daily
Pravastatin 40mg PO daily
Naproxen 600mg PO BID prn joint pain
Alprazolam 2mg PO BID prn anxiety
Sildenafil 10mg PO daily
***Allergies: Sulfa drugs
Assessment:
Head, eyes, ears, nose, and throat (HEENT)
No noted rashes, ecchymosis, or uneven hair distribution; eyes PERRLA, nasal passages patent with no flaring noted; dentition intact, mucous membranes – pink and dry.
Cardiac
S1,S2 noted on auscultation, patient has a pale presentation, apical rate of 120; no edema noted, pulses weak to upper and lower extremities, but palpable bilaterally.
Respiratory
Clear lung sounds to all fields both anteriorly and posteriorly.
GI
Noted watery stool to bedside commode; x2 episodes of vomiting; bowel sounds hyperactive with noted borborygmi.
GU
No discharge or bleeding; skin intact, patient is circumcised
Musculoskeletal
Patient has a weak presentation, with noted lethargy, noted assistance needed to get to commode.
Vital signs
BP – 90/55
HR – 126
Resp – 26
Temp 100.9 oral
SpO2 – 92%
Pain – 10/10 diffuse abdominal pain, described as cramping and twisting.
The physician orders…
Labs
Imaging
Medications
Complete blood count (cbc)
Complete metabolic profile (cmp)
Urinalysis
Stool culture
Chest x-ray
Non-contrast CT of abdomen and pelvis
NS 0.9% 1L bolus
Ondansetron 4mg IV
Famotidine 20mg IV
Morphine 2mg IV
Loperimide 2mg IV
Dicyclomine 20mg IM
Results are in…
Red blood cell
7.7
White blood cell
18
Hemoglobin
17.2
Hematocrit
56%
platelets
200
Na
150
K
3.2
Cl
110
Mg
1.2
BUN
30
Creat
2.0
Urinalysis
Negative for leukocytes
Stool culture
No abnormal bacteria, no blood noted
Chest X-ray results: no evidence of cardiopulmonary disease.
Non-contrast CT of abdomen and pelvis result: Significant colonic wall thickening indicative of enteritis.
Recommendation:
C is to be admitted to a general medical unit
Diagnosis: viral gastroenteritis
Control of nausea/vomiting with meds
Control of diarrhea with meds
IV hydration with NS @ 125ml/hr
PT eval in AM
Repeat labs in AM
Questions:
What areas of assessment would you prioritize? Please explain your answers.
Formulate 3 nursing diagnosis and list them by priority for this patient. Be sure to explain why you tanked the diagnosis the way you did.
The physician has ordered morphine for pain. Doesn’t this seem like a contraindication given the patient’s symptoms. Explain why you agree or disagree with this statement.
Examine the patient’s lab results. How would you correlate them to the symptoms the patient is experiencing? Please be sure to explain your answer.
What specific diet would you recommend for this patient? Why?
SCIENCE
HEALTH SCIENCE
NURSING
MICROBIOLOGY 123
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