Question: Nursing assessment of a client with gastrointestinal complaints

24 Sep 2024,7:26 PM

 

Overview
This case study will explore nursing assessment of a client with gastrointestinal complaints. You will refine your approach in creating a problem list with nursing interventions that align to provide holistic nursing care.

Tasks
Review the following information:
Situation: Clinic visit: 32-year-old with abdominal pain
Background: J.K. is a 32-year-old with history of obesity who presents with 7-day history of right upper quadrant abdominal pain, fever, nausea, and vomiting. J.K. was seen last month for
similar symptoms and diagnosed with constipation. This episode is much worse than last month.
Assessment: Client is in moderate distress, abdominal guarding, and frequent dry heaving.

Vital signs: HR 132, RR 26, BP 152/88, T 39.2C, Pox 96%, Pain Scale10/10

What 3 questions would be highest in priority to ask when completing the history of present illness?
What specific questions would you include if completing a focused review of systems for this client?
If the client was not able to provide subjective information due to pain, what alternatives or strategies could you consider?
What are normal vital sign ranges for this client? For each abnormal vital sign, provide a possible rationale for the abnormality.
Create a problem list with associated nursing care plan for this client using available background and assessment information.
For each problem, uses NANDA formatting from the Ackley and Ladwigs Nursing Diagnosis
Handbook textbook to select one nursing diagnosis pertinent to the problem and one proposed nursing intervention.

For example:
Problem: Fever of 39.2
Nursing Diagnosis: Ineffective thermoregulation (hyperthermia) related to dehydration and potential infection as evidenced by temperature of 39.2C.
Nursing Intervention: Implement measures to reduce body temperature such as removing excess blankets or clothing and administering and antipyretic as prescribed by the provider.

 

DRAFT/STUDY TIPS

Introduction

In nursing practice, a holistic approach to patient care is crucial, particularly when dealing with complex cases involving gastrointestinal complaints. This case study focuses on the nursing assessment of a 32-year-old male patient, J.K., presenting with right upper quadrant (RUQ) abdominal pain, fever, nausea, and vomiting. The primary goal of this essay is to critically examine the nursing assessment process, propose a problem list, and outline a corresponding nursing care plan using the NANDA format. This comprehensive analysis will incorporate relevant literature, clinical theories, and examples to provide a structured and evidence-based approach to nursing care. The thesis of this paper is that an effective nursing assessment and care plan are vital in addressing the physical, emotional, and psychological needs of patients, ensuring a holistic approach to healthcare.

Priority Questions for History of Present Illness

The initial stage in any nursing assessment is gathering a thorough history of the present illness (HPI). In this case, three critical questions should be prioritized to gather crucial information regarding J.K.'s abdominal pain:

1. When did the pain begin, and what were you doing when it started? This question helps determine the onset and possible trigger for the pain, which is essential in differentiating between acute and chronic conditions. For instance, gallbladder-related pain (such as cholecystitis) typically worsens after meals high in fat, providing clues to the underlying cause (Williams & Hopper, 2015).
2. Can you describe the characteristics of your pain? Is it sharp, dull, cramping, or burning? Understanding the nature of the pain helps narrow down the possible diagnoses. Sharp, stabbing pain in the RUQ may suggest gallstones or a biliary tract obstruction, while dull, cramping pain might indicate a gastrointestinal obstruction or inflammation (Ignatavicius & Workman, 2020).
3. Have you noticed any changes in your bowel habits, such as diarrhea or constipation? This question is critical because gastrointestinal symptoms often accompany RUQ pain, and any changes in bowel movements can guide the diagnosis (e.g., constipation vs. diarrhea in conditions like irritable bowel syndrome or inflammatory bowel disease) (Ackley & Ladwig, 2019).

By focusing on these high-priority questions, the nurse can collect vital information that will aid in the formation of a more accurate diagnosis and appropriate interventions.

Focused Review of Systems

A focused review of systems (ROS) is an extension of the patient history that narrows down relevant body systems based on the presenting symptoms. In J.K.’s case, the most critical systems to assess include:

1. Gastrointestinal System: Additional questions should explore symptoms such as bloating, changes in appetite, stool consistency, or the presence of blood in stools. These questions can help differentiate between various gastrointestinal disorders such as gastritis, peptic ulcer disease, or pancreatitis (Lewis et al., 2019).
2. Hepatobiliary System: Since J.K. has RUQ pain, assessing the liver and gallbladder is crucial. Questions should focus on jaundice (yellowing of the skin or eyes), dark urine, or light-colored stools, as these symptoms could indicate liver or gallbladder dysfunction (Ignatavicius & Workman, 2020).
3. Infectious Disease: Given J.K.’s fever, the ROS should include questions related to recent travel, exposure to contaminated food or water, and any known infections. Fever could indicate an infection such as cholangitis, which is common in patients with gallstones (Ackley & Ladwig, 2019).

By conducting a focused ROS, the nurse can gather information that may reveal other affected systems, helping to refine the diagnosis and guide treatment.

Alternatives When the Patient Cannot Provide Subjective Information

In some situations, a patient may be unable to provide subjective information due to pain or other factors. In J.K.’s case, if his pain is too severe for him to answer questions, alternative strategies must be employed to gather the necessary information. These strategies include:

1. Observation: The nurse should closely observe the patient's body language, facial expressions, and behavior. For instance, abdominal guarding and grimacing can indicate severe pain, while dry heaving may suggest gastrointestinal irritation (Jarvis, 2019).
2. Family or Caregiver Input: If the patient has a family member or caregiver present, they can provide valuable information about the onset of symptoms, changes in behavior, or other relevant history that the patient is unable to communicate (Craven & Hirnle, 2016).
3. Medical Records and Previous Visits: Reviewing the patient’s medical history, including previous visits for similar complaints, can offer clues to the current condition. For example, J.K. had a similar episode last month, which could point to a recurring condition that needs further investigation (Ackley & Ladwig, 2019).

Using these alternative methods, the nurse can still gather essential data even when the patient is unable to verbally communicate due to pain.

Vital Sign Ranges and Abnormalities

In this case, J.K.'s vital signs are abnormal, indicating the need for further assessment and intervention. The normal ranges for an adult are as follows: heart rate (HR) 60-100 beats per minute (bpm), respiratory rate (RR) 12-20 breaths per minute, blood pressure (BP) 120/80 mmHg, and temperature (T) 36.5-37.5°C (Jarvis, 2019).

• HR of 132 bpm: Tachycardia can be explained by pain, fever, dehydration, or infection. In this case, the elevated heart rate could be a physiological response to pain and fever (Lewis et al., 2019).
• RR of 26 breaths per minute: Tachypnea may indicate respiratory compensation for metabolic acidosis, pain, or fever. Given the fever and potential infection, an elevated respiratory rate is consistent with the body’s attempt to manage metabolic changes (Ignatavicius & Workman, 2020).
• BP of 152/88 mmHg: Elevated blood pressure may result from pain, anxiety, or fever. Pain is a likely factor in this case, considering the patient’s 10/10 pain scale rating (Williams & Hopper, 2015).
• T of 39.2°C: Fever indicates an inflammatory or infectious process. The combination of fever, RUQ pain, and vomiting could suggest an acute infection such as cholecystitis (Ackley & Ladwig, 2019).

Recognizing these abnormalities allows the nurse to prioritize interventions aimed at stabilizing the patient.

Problem List and Nursing Care Plan

Based on J.K.’s symptoms and vital signs, several problems can be identified, and appropriate nursing diagnoses and interventions must be developed.

1. Problem: Fever (39.2°C)

   • Nursing Diagnosis: Ineffective thermoregulation (hyperthermia) related to potential infection and dehydration as evidenced by fever of 39.2°C.
   • Nursing Intervention: Administer antipyretics as prescribed and implement cooling measures (e.g., removing excess blankets). Encourage fluid intake if tolerated to prevent dehydration (Ackley & Ladwig, 2019).

2. Problem: Abdominal Pain (10/10 on pain scale)

   • Nursing Diagnosis: Acute pain related to gastrointestinal or hepatobiliary inflammation as evidenced by the patient's pain rating of 10/10 and abdominal guarding.
   • Nursing Intervention: Administer prescribed analgesics and consider non-pharmacological pain management techniques such as positioning and relaxation strategies (Craven & Hirnle, 2016).

3. Problem: Nausea and Vomiting

   • Nursing Diagnosis: Nausea related to gastrointestinal disturbance as evidenced by frequent dry heaving and vomiting.
   • Nursing Intervention: Administer antiemetics as prescribed and provide small, frequent sips of clear fluids to prevent dehydration (Williams & Hopper, 2015).

Conclusion

In conclusion, nursing assessments play a crucial role in identifying the root cause of gastrointestinal complaints like those experienced by J.K. By asking high-priority questions, conducting a focused review of systems, utilizing alternative assessment strategies, and identifying abnormal vital signs, nurses can create a comprehensive problem list and care plan that addresses the patient's immediate and long-term needs. This case study highlights the importance of a holistic, patient-centered approach in nursing practice, ensuring that both physical and emotional aspects of care are considered. Through evidence-based interventions and the application of nursing theories, healthcare professionals can provide optimal care that promotes recovery and improves patient outcomes.