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.
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:
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:
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:
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).
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.
Problem: Fever (39.2°C)
Problem: Abdominal Pain (10/10 on pain scale)
Problem: Nausea and Vomiting
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.
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