Chief Complaint History of Present Illness Rapid Reasoning: Appendicitis Jennifer Anderson is 42 year old woman who pres

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Chief Complaint History Of Present Illness Rapid Reasoning Appendicitis Jennifer Anderson Is 42 Year Old Woman Who Pres 1 (81.36 KiB) Viewed 40 times

Chief Complaint History Of Present Illness Rapid Reasoning Appendicitis Jennifer Anderson Is 42 Year Old Woman Who Pres 2 (43.71 KiB) Viewed 40 times

Chief Complaint History of Present Illness Rapid Reasoning: Appendicitis Jennifer Anderson is 42 year old woman who presents to the ED with a chief complaint of abdominal pain that has now become located in the RLO is nauseated, but has had no emesis Appears comfortable but is The pain started gradually 12 hours ago shortly after eating dinner She describes as a general red abd poin Past Medical History: DVT W/PE. Warfarin (Coumadin) daily Your Initial VS: WILDA Pain Scale 5 VS) Words: Sharp T: 100,5 (0) Intensity B/10 P: 92 Location: RL@abd R: 20 Duration Aggreviate: Movement and car ride bumps Continuous since onset 10 hours ago BP: 130/70 02 sats: 96% RA Alleviate: None Your Initial Nursing Assessment: GENERAL APPEARANCE: resting comfortably in semi-fetal position RESP: breath sounds clear with equal aeration bilat, non-labored CARDIAC: pink, warm & dry, S1S2, no edema, pulses 3+ in all extremities NEURO: alert & oriented X4 GUIGU: Abd soft active BS in all quads, RLQ has rebound tenderness, volding without difficulty. Denies painful/burning urination. Remains nauseated. Nursing Interventions: UA (ED standing order), Urine pregnancy test (UPT) (ED standing order) Physician Orders: Establish PIV Morphine 2-4 mg IV every 30" prn pain Ondansetron (Zofran) 4 mg IV prn every 4 hours nausea Strict NPO CBC, BMP CT abd/pelvis Phytonadione (Vitamin K) 5 mg IV UA Current Fresh Frozen Plasma (FFP) 2 units IV stat Color (yellow) Yellow Clear Prepare for OR/surgical consult Clarity (clear) 1.015 Lab/diagnostic Results: Sp. Grav (1.002-1.030) Urine Pregnancy: neg Protein (neg) Neg CT abd/pelvis: acute inflammation of appendix consistent wlappe Glucose (neg) Neg Neg Ketones (neg) Lab Test Current High/Low Blood (neg) Neg Sodium 138 Nitrate (neg) Neg Potassium 3.9 LET (neg) Neg Creatinine 0.9 RBC's (0-2) 0 WBC 9.7 WBC's (0-5) 2 Neut. % 93 Bacteria (0-few) 0 Hgb. 14.8 Epithelial (0-few) 0 INR 2.5 2012 Keith Rischer/www.KeithRN.com . . .

6.What interventions will you initiate based on this priority? Nursing Interventions Rationale: 1. Expected Outcome: 1. 2 2. 3. 3 3 7. What is the relationship between the following nursing physician orders and your patient's primary medical problem? (How will mech of action of these meds/treatments impact this patient at a pathophys level to help resolve primary problem?). Physician orders: Rationale: Expected Outcome: Establish PIV Morphine 2-4 mg IV every 30 pm Ondansetron (Zofran) 4 mg IV Strict NPO CBC BMP CT abd/pelvis Phytonadione (Vitamin K) 5 mg IV Fresh Frozen Plasma (FFP) 2 units IV stat Prepare for OR/surgical consult 2012 Keith Rischer/www.KeithRN.com