Student-Appe- Unfolding Reasoning

Safe and Effective Care Environment Management of Care 17-23% Safety and Infection Control 9-15% Health Promotion and Maintenance 6-12% Psychosocial Integrity 6-12% Physiological Integrity Basic Care and Comfort 6-12% Pharmacological and Parenteral Therapies 12-18% Reduction of Risk Potential 9-15% Physiological Adaptation 11-17% 1 History of Present Problem: John Washington is a healthy 14-year-old African American male who weighs 150 lbs. (68.2 kg). He came to the emergency department because he woke up this morning at about 2 am with "excruciating" generalized abdominal pain around his belly button that has been progressively getting worse over the past several hours. It is now 2 pm. He took ibuprofen 400 mg PO this morning, which decreased the pain some but is now more painful and uncomfortable. The pain is now localized to his RLQ. The pain increases with walking and movement but he feels better when he lies down in a fetal position. He vomited three times after he drank some orange juice for breakfast this morning and has had nothing to drink since. He continues to feel nauseated but has not had an emesis since this morning. Personal/Social History: John lives with his mother and three younger brothers. He is active in athletics and has a strong social network of friends and family in the inner-city neighborhood where he lives. What data from the histories are RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential) RELEVANT Data from Present Problem: Clinical Significance: -14 years old -Excruciating generalized abdominal pain around the belly button -Current localized pain to RLQ -Increased pain on exertion -Decreased pain in fetal position -Nausea/Vomiting - Appendicitis is commonly seen in patients age 10-30 -Progressing pain could be the result of occlusion which could lead to inflammation then pain -Fetal position relieves pressure -Movement/exertion increases pressure -Nausea and RELEVANT Data from Social History: Clinical Significance: -John is a minor -Active in athletics -Strong network of friends and family . -Parent needs to consent for him -At risk for ineffective coping -Must consider family and friends and how they will be impacted by the brothers surgery Patient Care Begins: Current VS: P-Q-R-S-T Pain Assessment: T: 100.5 F/38.1 C (oral) Provoking/Palliative: Movement, palpation P: 106 (regular) Quality: Sharp, cramping R: 20 (regular) Region/Radiation: Mid abdomen, RLQ BP: 142/76 Severity: 8/10 2 O2 sat: 99% RA Timing: Continuous What VS data are RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential/Health Promotion and Maintenance) RELEVANT VS Data: Clinical Significance: -Fever -Tachycardia -8/10 pain -146/76 BP -Sharp, cramping, continuous pain -Fever can be a sign of infection -Pain level indicative of inflammation -Elevated vital signs could be sign of peritonitis