History of Present Problem: Sean Donald is a 55-year-old male with…

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

Basic Metabolic Panel (BMP)
	Na	K	Gluc.	Creat.
Current:	134	4.8	8.0	1.9
Complete Blood Count (CBC)
	WBC	HGB	PLTs	% Neuts
Current:	8.5	55 g/L	68	75
Liver Panel
	Albumin	Total Bili	Alk. Phos.	ALT	AST
Current:	2.1	3.5	152	68	75
MISC.
	Lactate	Mg	PT/INR
Current:	3.4	1.3	8.5

1.Describe a situation that required you as the nurse to formulate a correct clinical judgment to either advance the plan of care or to recognize clinical data that represented a change in clinical status in the case study

2. What can be learned from it

3. What would you do differently?

4. How you can use this knowledge in the future

Explanation & Answer

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