I human Case Study-Dorothy Jones, 54 years old Female, CC: Abdominal Pain, Exams of Nursing

Download I human Case Study-Dorothy Jones, 54 years old Female, CC: Abdominal Pain and more Exams Nursing in PDF only on Docsity! Dx: SBO Feedback: the patients presentation w/ acute mid-abdominal pain, distention, nausca/vomiting, constipation and inability to pass gas is consistent with SBO. An abdominal series confirms the present of multiple dilated loops of small bowel. Her history of 2 prior abdominal surgeries significantly increases the likelihood of her bowel obstruction being secondary to postsurgical adhesions. Approximately 93% of all patients who have had prior abdominal surgery have adhesions; of whom 14% willrequire intervention for adhesion-related sequelae within 10 years of their surgery. Problem statement: Dorothy Jones is a 54 year old female that presents with acute, progressive abdominal pain for 3days. She complains of absence flatus, emesis and abdominal distention. Past medical history includes hysterectomy removal 2 years ago, cholecystectomy 15 years ago, hyperlipidemia and constipation. Upon assessment, patient noted to be tachycardic, obese, absent bowel sounds, periumbilical discomfort to palpation, distended abdomen and tympany noted on percussion. Ms. Jones is awake, alert and oriented x4. No acute distress. Patient is age appropriate and looks uncomfortable. Her vital signs are as follows: blood pressure 128/72, pulse 100 beats per minute, 37 degrees Celsius (98.6 degrees Fahrenheit), respiration rate is 18 and oxygen level is 98%. Upon assessment, her HEENT/Neck is normal. PMI is in the 5" intercostal space at the midclavicular line. Normal jugular venous pressure but is noted to have tachycardia. Her chest is symmetrical and no use of accessory muscles are noted while breathing. All superficial thoracic lymph nodes are non-palpable, of normal size and consistent throughout. Anterior lung fields are resonant. The left anterior chest and right lower chest are dull. The rest of lung fields are resonant. Lung sounds bilaterally are normal. The abdomen is atraumatic, mildly obese, symmetrical, slightly taut and distended. Surgical scars noted. No visible peristalsis, mass or organomegaly. Mild discomfort throughout abdominal palpation and occasional palpable peristalsis. No involuntary guarding or rebound tenderness noted. Upon percussion, modcratelytympanitic noted. Normal girth. Absent bowel sounds. Paticnt has no problem with her genitourinary or rectum. She has noted however that her urine is darker than normal. She has normal and equal ROM bilaterally. Her gait is steady.