hello   Part I: Recognizing RELEVANT Clinical Data History of…

hello

 

Part I: Recognizing RELEVANT Clinical Data

History of Present Problem:

Sean Donald is a 55-year-old male with a history of cirrhosis and ETOH abuse who has not had any medical care the last ten years. He began vomiting large amounts of bright red blood when he woke up this morning. He was found on the floor of the bathroom by Sheila, his girlfriend, when he became lightheaded and fell on the floor and was too weak to get up. Sheila called 911.

Paramedics report that there was a large dark red/black stool in the toilet. They were able to get an 18-gauge IV in the right antecubital vein, and Jim received 500 mL of 0.9% NS. His initial BP was 80/40 at the scene, and his most recent BP is 82/44 with a current heart rate of 128, sinus tachycardia.

 

Personal/Social History:

Sean recently lost his job as a construction laborer and was divorced six months ago. His ex-wife has full custody of his two children. Sean’s girlfriend states that he has been more depressed lately and has been drinking more heavily since his divorce. He takes ibuprofen daily for chronic back pain.

 

Current VS:	P-Q-R-S-T Pain Assessment:
T: 98.2 F/36.8 C (oral)	Provoking/Palliative:
P: 138 (regular)	Quality:	Denies
R: 28 (regular)	Region/Radiation:
BP: 74/30 MAP: 45	Severity:
O2 sat: 95% room air	Timing:

Current Assessment:
GENERAL APPEARANCE:	Lethargic, body tense, appears uncomfortable but denies pain
RESP:	Breath sounds clear with equal aeration bilaterally ant/post, non-labored respiratory effort
CARDIAC:	Pale, extremities cool, no edema, heart sounds regular with no abnormal beats, pulses weak, equal to palpation at radial/pedal/post-tibial landmarks, 1-2 second capillary refill
NEURO:	Alert & oriented to person, place, time, and situation (x4), whispers responses
GI:	Abdomen flat, soft/non-tender, bowel sounds audible per auscultation in all four quadrants, feels nauseated
GU:	No urine output present
SKIN:	Skin integrity intact, skin turgor elastic, no tenting present

Questions

1. The patient’s primary problem (medical diagnosis)?

2.  Define and describe the pathophysiology of your patient’s primary problem simple word?

4.Using non-medical terminology, how would you explain and teach your patient about the pathophysiology of this medical problem?

5.What body system(s) is(are) directly affected by this disease, and how are those systems affected?

 

BODY SYSTEM(S):	HOW BODY SYSTEM IS AFFECTED(S):

6.  WHAT ARE THE PRIMARY NURSING EVALUATIONS WITH THIS DISEASE? (Insert the body system that is most affected here.) 

PRIORITY ASSESSMENTS:	EXPECTED ABNORMAL ASSESSMENTS:

7. What lab tests are affected by this issue? What effect does this have on the lab tests? Is the altered lab test having an effect on any physical assessment findings?

ABNL. LAB TESTS:	HOW LAB TESTS AFFECTED:	DOES IT IMPACT ASSESSMENTS?
l

8. What medications are most commonly used to treat this condition?

MEDICATIONS:	MECHANISM OF ACTION (OWN WORDS):

Explanation & Answer

Our website has a team of professional writers who can help you write any of your homework. They will write your papers from scratch. We also have a team of editors just to make sure all papers are of HIGH QUALITY & PLAGIARISM FREE. To make an Order you only need to click Order Now and we will direct you to our Order Page at Litessays. Then fill Our Order Form with all your assignment instructions. Select your deadline and pay for your paper. You will get it few hours before your set deadline.