Case Study
A 22 year old female has been brought to the emergency room after fainting at home with complaints of flu-like symptoms for the last eight days (GCU, 2010). She has reported vomiting several times a day and having difficulty keeping food or liquids down. She states she has been “taking more than the recommended dose of antacids to help with nausea symptoms”. She has become dehydrated, so an IV has been placed and fluids have been started. She also has had an arterial blood gas (ABG) drawn that has shown acid-base deficits. This paper will discuss how a focused history, physical exam, nursing diagnosis and the nursing process of care is important in helping this patient get better. It will also discuss the differences between …show more content…
Patient was started on IV fluids to help replace fluid loss. She may also be prescribed a low-fat, liquid diet or may remain nothing by mouth (NPO). Many times in this nurse’s experience, these patients are kept NPO until the etiology is found out as it may aggravate the stomach and cause increased vomiting. “If an etiology is identified, a targeted therapy can be provided; however, delays in evaluation may require empiric treatment for patient comfort” (Jarvis, 2011).The assessment does not say if this patient was given any antiemetics for the nausea/vomiting but it would be reasonable to start her on one. Studies have found that a serotonin antagonist (Zofran) is most beneficial unless the patient has an allergy to it (Jarvis, 2011). The case study does not address if there are any allergies which can lead to an unwanted reaction. If continuous gastric suction is necessary, an H2 blocker or PPI would be added to decrease gastric secretions. Supplements with potassium would be given to prevent hypokalemia from volume resuscitation. Labs done to monitor electrolytes in the blood and urine. Vital signs monitoring for any dynamic changes in blood pressure, pulse, respirations, oxygen levels, and temperature. Monitoring patient’s daily weight helps to assess …show more content…
Assessments examine patients’ life in detail so that correct diagnosis, suitable treatment post, problem lists, and treatment goals can be developed (DiCenso, Guyatt, & Ciliska, 2014). Different types of assessments are used according to the situation at that particular time. A complete or comprehensive nursing assessment is usually done at the time of the patient’s admission which includes historical data, chief complaint, history of present illness, review of systems, pertinent medication or allergies, patient history, general appearance, physical examination and vital signs. Whereas, a focused assessment is a detailed nursing assessment of specific body system(s) relating to the presenting problem or current concern(s) of the patient. This case study assessment has limited information that prevents this author from giving an accurate focused or complete assessment. It is important that a nurse has a complete picture of what is going on with her patient. This may include verbal, nonverbal or reactions from the patient as not all patients are able to give appropriate information. Many hospitals have different measuring tools to help with the process. Currently, at this author’s hospital, we use different grading scores that can assess these different types of patients. For example, a patient that is unable to talk an ANVPS that accesses different
A 22 year old female has been brought to the emergency room after fainting at home with complaints of flu-like symptoms for the last eight days (GCU, 2010). She has reported vomiting several times a day and having difficulty keeping food or liquids down. She states she has been “taking more than the recommended dose of antacids to help with nausea symptoms”. She has become dehydrated, so an IV has been placed and fluids have been started. She also has had an arterial blood gas (ABG) drawn that has shown acid-base deficits. This paper will discuss how a focused history, physical exam, nursing diagnosis and the nursing process of care is important in helping this patient get better. It will also discuss the differences between …show more content…
Patient was started on IV fluids to help replace fluid loss. She may also be prescribed a low-fat, liquid diet or may remain nothing by mouth (NPO). Many times in this nurse’s experience, these patients are kept NPO until the etiology is found out as it may aggravate the stomach and cause increased vomiting. “If an etiology is identified, a targeted therapy can be provided; however, delays in evaluation may require empiric treatment for patient comfort” (Jarvis, 2011).The assessment does not say if this patient was given any antiemetics for the nausea/vomiting but it would be reasonable to start her on one. Studies have found that a serotonin antagonist (Zofran) is most beneficial unless the patient has an allergy to it (Jarvis, 2011). The case study does not address if there are any allergies which can lead to an unwanted reaction. If continuous gastric suction is necessary, an H2 blocker or PPI would be added to decrease gastric secretions. Supplements with potassium would be given to prevent hypokalemia from volume resuscitation. Labs done to monitor electrolytes in the blood and urine. Vital signs monitoring for any dynamic changes in blood pressure, pulse, respirations, oxygen levels, and temperature. Monitoring patient’s daily weight helps to assess …show more content…
Assessments examine patients’ life in detail so that correct diagnosis, suitable treatment post, problem lists, and treatment goals can be developed (DiCenso, Guyatt, & Ciliska, 2014). Different types of assessments are used according to the situation at that particular time. A complete or comprehensive nursing assessment is usually done at the time of the patient’s admission which includes historical data, chief complaint, history of present illness, review of systems, pertinent medication or allergies, patient history, general appearance, physical examination and vital signs. Whereas, a focused assessment is a detailed nursing assessment of specific body system(s) relating to the presenting problem or current concern(s) of the patient. This case study assessment has limited information that prevents this author from giving an accurate focused or complete assessment. It is important that a nurse has a complete picture of what is going on with her patient. This may include verbal, nonverbal or reactions from the patient as not all patients are able to give appropriate information. Many hospitals have different measuring tools to help with the process. Currently, at this author’s hospital, we use different grading scores that can assess these different types of patients. For example, a patient that is unable to talk an ANVPS that accesses different