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Student Name:
Student Number:
Date: 15/6/2021
Client’s Name: M.J
DOB: 1/1/1998 Age: 22 Marital Status: Single
Religion: Muslim Occupation: Student
Admitted from: Emergency Department
Mode of Arrival: Private vehicle
Reason For admission:
Patient presents with abdominal pain. Other symptoms include vomiting.
Past medical & surgical history:
No past medical or surgical history
History of medication use at home:
No medication being used at home.
Family History:
Patient has no presence of family history problems.
Current Medical Diagnosis:
Appendicitis.
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Subjective Data:
Patient woke up in the middle of the night complaining of abdominal pain which was
generalized and described as colicky. The severity of the pain was severe. Pain was episodic
and has lasted for one night. She scored the breakthrough pain as 9/10 on the numeric pain
scale and decreases to a score of 4/10 after analgesia administration. Radiation of pain: none.
Exacerbating factors consist of none. Relieving factors consist of none. Symptoms include
vomiting. Denies fever, diarrhea, or constipation. The mother took her to a general
practitioner in Al Rahba hospital in which he referred her to Burjeel hospital, however, she
was told that there was no gastrointestinal specialist in Burjeel which made her decide to
bring her daughter to SKMC. After the patient underwent an ultrasound test, it revealed
appendicitis.
Objective data:
Vital signs including pain assessment
Blood pressure= 84/53 mmHg Normal (according to baseline)
Heart rate= 71 bpm Normal (according to baseline)
Temperature= 36.9°c
Respiratory rate= 20 bpm
SpO
2
= 99% - Normal
Numeric pain scale: 4/10
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Physical Assessment
General: Patient is oriented to time, place, and person. No acute distress. Displays a neutral facial
expression
Head: Appropriate size for age, symmetrical.
Integumentary: Her skin is intact and has good turgor (assessed dorsal part of hand and
supraclavicular region) and no edema. She has an IV cannula on her right hand.
ENT: Ear is intact, clear tympanic membrane, no nasal congestion, patent nose. Lymph nodes not
palpable.
Eyes: PERRLA
Musculoskeletal: Normal ROM
Respiratory: Lungs are clear to auscultation, sounds are equal, symmetrical chest expansion.
RR=20bpm
Cardiovascular: Normal heart rate of 71 bpm, regular, force = +2
Neurological: GCS = 15/15, alert and oriented.
Gastrointestinal: Vomiting is present. No diarrhea. Generalized abdominal pain. soft tenderness
over the right iliac and suprapubic regions. Patient must remain NPO before undergoing
appendectomy.
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LABORATORY TESTS:
Test Category
Test Name
Normal Range
Patient
Specific
Lab
Values
Result Interpretation
General
Chemistry
Cl
-
C-Reactive
Protein
WBC
98-107 mmol/L
Less than 5.0
mg/L
3.9-5.10/L
95 mmol/L
9.48 mg/L
20.0x10^9/L
Chloride levels within
normal range.
C-RP levels are high. Patient
has inflammation.
WBC levels are high due to
inflammation of the
appendix.
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DIAGNOSTIC TESTS:
Test name
Specific findings for patient
Abdominal ultrasound scan
Appendicitis ruled out. Thickened
appendix measuring 1.2cm in
thickness. No collection present
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MEDICATIONS:
Drugs Order/ Dosage/ Route/
Frequency
Mode of
drug actions/
Classifications
Indications
Adverse effects
Nursing consideration
Scheduled Medication:
Amoxicillin
875 mg, INJ, IV, q8hr
Amoxicillin is
similar to
penicillin in its
bactericidal action
against susceptible
bacteria during the
stage of active
multiplication. It
acts through the
inhibition of cell
wall biosynthesis
that leads to the
death of the
bacteria.
Used to fight
different types of
infection caused
by bacteria.
Nausea, Vomiting,
diarrhea, rash.
Monitor signs of
pseudomembranous
colitis, including
diarrhea, abdominal
pain, fever, pus or
mucus in stool, and
other severe or
prolonged GI
problems (nausea,
vomiting, heartburn).
PRN Medication:
Acetaminophen
1000 mg, INJ, IV q6hr
It provides
temporary
analgesia for mild
to moderate pain.
In addition,
acetaminophen
lowers body
temperature in
individuals with a
fever.
For short term
pain
management.
Patient was
reporting pain.
Loss of appetite,
itching,
rash,
headache, dark
urine.
Safe administration,
monitoring for
efficacy, and
identifying any
possible adverse
reaction. Instruct
patient to report dark
urine, rash, or
itchiness.
Continuous Infusions:
Dextrose 5% with 0.45%
NaCl
990 mL, INJ, IV, 85 mL/Hr.
Infuse over 11.8 hours, 1000
mL in total.
Isotonic IV fluid//
Is a source of
water, electrolytes,
and calories for
the patient.
Patient must
remain NPO
before
undergoing
appendectomy
so this is given
for fluid
replacement
Hypervolemia,
hypernatremia,
hypercalcemia,
hyperglycemia.
Routine blood sugar
check, and blood
general chemistry
checks. Assess for
signs of
hypervolemia such
as elevated BP.
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Unformatted Attachment Preview

Student Name: Student Number: Date: 15/6/2021 Client’s Name: M.J DOB: 1/1/1998 Age: 22 Marital Status: Single Religion: Muslim Occupation: Student Admitted from: Emergency Department Mode of Arrival: Private vehicle Reason For admission: Patient presents with abdominal pain. Other symptoms include vomiting. Past medical & surgical history: No past medical or surgical history History of medication use at home: No medication being used at home. Family History: Patient has no presence of family history problems. Current Medical Diagnosis: Appendicitis. Subjective Data: Patient woke up in the middle of the night complaining of abdominal pain which was generalized and described as colicky. The severity of the pain was severe. Pain was episodic and has lasted for one night. She scored the breakthrough pain as 9/10 on the numeric pain scale and decreases to a score of 4/10 after analgesia administration. Radiation of pain: none. Exacerbating factors consist of none. Relieving factors consist of none. Symptoms include vomiting. Denies fever, diarrhea, or constipation. The mother took her to a general practitioner in Al Rahba hospital in which he referred her to Burjeel hospital, however, she was told that there was no gastrointestinal specialist in Burjeel which made her decide to bring her daughter to SKMC. After the patient underwent an ultrasound test, it revealed appendicitis. Objective data: Vital signs including pain assessment Blood pressure= 84/53 mmHg – Normal (according to baseline) Heart rate= 71 bpm – Normal (according to baseline) Temperature= 36.9°c Respiratory rate= 20 bpm SpO2 = 99% - Normal Numeric pain scale: 4/10 Physical Assessment • • • • • • • • • • General: Patient is oriented to time, place, and person. No acute distress. Displays a neutral facial expression Head: Appropriate size for age, symmetrical. Integumentary: Her skin is intact and has good turgor (assessed dorsal part of hand and supraclavicular region) and no edema. She has an IV cannula on her right hand. ENT: Ear is intact, clear tympanic membrane, no nasal congestion, patent nose. Lymph nodes not palpable. Eyes: PERRLA Musculoskeletal: Normal ROM Respiratory: Lungs are clear to auscultation, sounds are equal, symmetrical chest expansion. RR=20bpm Cardiovascular: Normal heart rate of 71 bpm, regular, force = +2 Neurological: GCS = 15/15, alert and oriented. Gastrointestinal: Vomiting is present. No diarrhea. Generalized abdominal pain. soft tenderness over the right iliac and suprapubic regions. Patient must remain NPO before undergoing appendectomy. LABORATORY TESTS: Test Category General Chemistry Test Name Normal Range Patient Specific Lab Values Cl- 98-107 mmol/L 95 mmol/L C-Reactive Protein Less than 5.0 mg/L 9.48 mg/L WBC 3.9-5.10/L 20.0x10^9/L Result Interpretation Chloride levels within normal range. C-RP levels are high. Patient has inflammation. WBC levels are high due to inflammation of the appendix. DIAGNOSTIC TESTS: Test name Abdominal ultrasound scan Specific findings for patient Significance of results in relation to the disease process for this patient including nursing implication of care Appendicitis ruled out. Thickened The cause of abdominal pain is appendix measuring 1.2cm in due to appendicitis. thickness. No collection present MEDICATIONS: Drugs Order/ Dosage/ Route/ Frequency Scheduled Medication: Amoxicillin 875 mg, INJ, IV, q8hr PRN Medication: Acetaminophen 1000 mg, INJ, IV q6hr Mode of drug actions/ Classifications Indications Amoxicillin is Used to fight Nausea, Vomiting, similar to different types of diarrhea, rash. penicillin in its infection caused bactericidal action by bacteria. against susceptible bacteria during the stage of active multiplication. It acts through the inhibition of cell wall biosynthesis that leads to the death of the bacteria. It provides temporary analgesia for mild to moderate pain. In addition, acetaminophen lowers body temperature in individuals with a fever. For short term• pain • management. • Patient was reporting pain.• Isotonic IV fluid// Patient must Is a source of remain NPO water, electrolytes, before Dextrose 5% with 0.45% and calories for undergoing NaCl the patient. appendectomy 990 mL, INJ, IV, 85 mL/Hr. so this is given Infuse over 11.8 hours, 1000 for fluid mL in total. replacement Continuous Infusions: Adverse effects Nursing consideration Monitor signs of pseudomembranous colitis, including diarrhea, abdominal pain, fever, pus or mucus in stool, and other severe or prolonged GI problems (nausea, vomiting, heartburn). Loss of appetite, itching, rash, headache, dark urine. Safe administration, monitoring for efficacy, and identifying any possible adverse reaction. Instruct patient to report dark urine, rash, or itchiness. Hypervolemia, hypernatremia, hypercalcemia, hyperglycemia. Routine blood sugar check, and blood general chemistry checks. Assess for signs of hypervolemia such as elevated BP. 1. Nursing Diagnosis: Acute pain r/t disease pathophysiology a.e.b. patient reporting pain (9/10 score). Goals and Expected Outcomes Within 1 hour of administering analgesia, the patient will report a pain score of less than 34/10 on numeric pain scale. Nursing Interventions* 1. Acknowledge reports of pain immediately. 2. Assess pain using numeric pain scale. 3. Analgesic administration (Acetaminophen). Rationale for Nursing Interventions 1. An immediate response to Patient reports a pain score of reports of pain may decrease 4/10 after administering anxiety in the patient. acetaminophen. Demonstrated concern for the patient’s welfare and comfort fosters the development of trusting relationship. Promotes better pain management. 2. Assessment of pain experience is the first step in planning pain management strategies. This also obtains a baseline score for the patient to measure the outcome of interventions. 3. These medications relieve pain. Acetaminophen has been prescribed due to patient reporting pain. 4. Reassess pain using numeric pain scale. Evaluations 4. To measure the effectiveness of the interventions. 2. Nursing Diagnosis: Knowledge deficit r/t to disease process a.e.b. frequently asking questions related to treatment and surgery. Goals and Expected Outcomes Nursing Interventions* Patient will understand, have awareness and the ability to manage her condition autonomously. 1. Consider what is important to the patient 1. Allowing the patient to identify Patient’s and parents’ doubts the most significant content to be and concerns were cleared and by the physician and the presented first is the most healthcare team. effective 2. Provide clear, thorough, and understandable explanations and demonstrations. 2. Patients are better able to ask questions when they have basic information about what to expect. 3.Give information with the use of media. Use visual aids like diagrams, pictures, videotapes, audiotapes, and interactive Internet websites Rationale for Nursing Interventions 3. Different people take in information in different ways. Evaluations 3. Nursing Diagnosis: Risk for fall r/t sleepiness. Goals and Expected Outcomes Patient will not sustain fall and will be provided with adequate rest. Nursing Interventions* Rationale for Nursing Interventions Evaluations 1. Ensure that the beds are at the lowest possible position. If needed, set the patient’s sleeping surface as adjacent to the floor as possible. 1. Keeping the beds closer to the Patient did not sustain fall and floor reduces the risk of falls and was able to receive 6 hours of serious injury. In some sleep. healthcare settings, placing the mattress on the floor significantly reduces fall risk. 2. Use side rails on beds, as needed. For beds with split side rails, leave at least one of the rails at the foot of the bed down. 2. According to research, a 3. Respond to call light as soon as possible. 3. This is to prevent the patient from going out of bed without any assistance. 4. Provide a “Do not disturb” sign on the patient’s hospital room at bedtime. 4. To alert other members of the disoriented or confused patient is less likely to fall when one of the four rails is left down. medical team that the patient is not to be disturbed unless absolutely necessary to ensure that she receives an uninterrupted, good night’s sleep Name: Description: ...
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