Chief Complaint History of Present Illness Rapid Reasoning: Appendicitis Jennifer Anderson is 042 year old woman who pre

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Chief Complaint History Of Present Illness Rapid Reasoning Appendicitis Jennifer Anderson Is 042 Year Old Woman Who Pre 1 (81.13 KiB) Viewed 41 times

Chief Complaint History Of Present Illness Rapid Reasoning Appendicitis Jennifer Anderson Is 042 Year Old Woman Who Pre 2 (45.14 KiB) Viewed 41 times

Chief Complaint History of Present Illness Rapid Reasoning: Appendicitis Jennifer Anderson is 042 year old woman who presents to the ED with a chiof complaint of abdominal pain The pain started gradually 12 hours ago shortly after eating dinner. She describes it as a general red abd pain Past Medical History: pune ne dori-rotat position she start that the parte de frunzed when in this position DVT WIPE. Warfarin (Coumadin) daily Your Initial VS: WILDA Pain Scale 6 VS) Words Sharp T: 100,5 (0) Intensity 8/10 P: 92 Location RL abd R: 20 Duration: BP: 130778 Continuous since onset 10 hours ago Aggreviate: Movement and car ride bumps 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 Yellow Fresh Frozen Plasma (FFP) 2 units IV stat Color (yellow) Clear Prepare for OR/surgical consult Clarity (clear) Lab/diagnostic Results: Sp. Grav (1.002-1.030) 1.015 Urine Pregnancy: neg Protein (neg) Neg CT abd/pelvis: acute inflammation of appendix consistent w/appe Glucose (neg) Neg Ketones (neg) 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) WBC 9.7 2 WBC's (0-5) Neut. % 93 Bacteria (O-few) Hgb. 14.8 Epithelial (0-few) INR 2.5 © 2012 Keith Rischer/www.KeithRN.com . e ololo
6.What interventions will you initiate based on this priority? Nursing Interventions Rationale: 1. 1 Expected Outcome: 1. 2. 2 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 pathophyslevel 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