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. Explain why you chose these diagnoses for the patient. 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.
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 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. Explain why you chose these diagnoses for the patient.
- 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.
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