Jeanette is a 46-year-old woman who has visited her general practitioner (GP) today, brought in by her husband, Steve, with a 5-day history of nausea, mild abdominal pain and constipation. She decided to see the doctor today, as the pain and nausea were much worse when she woke up this morning and she has vomited twice in the past 3 hours. She also reports her abdomen feels distended and bloated. Jeanette says she had tried to drink more water and eat more fruit and was having bran for breakfast for the past 3 days, as she initially thought she was simply constipated. With the increased generalized abdominal pain and vomiting this morning, she thought she should get a medical opinion. Jeanette has a past medical history of hypercholesterolemia, hypertension, atrial fibrillation and type 2 diabetes mellitus (T2DM) and her BMI is 32 kg/m2. She experienced appendicitis 6 months ago, for which she had an appendectomy. Her current medications are simvastatin, warfarin, and metformin. The GP takes her vital signs which are: • BP – 163/87 mmHg • HR – 86 beats/minute • RR – 16 breaths/minute • T – 36.7°C • SpO2 – 97% with no supplemental oxygen Questions: What are the points of subjective data we can find in this patient's case? What are the points of objective data we can find in this patient's case? List your top 3 priorities for this patient. Formulate 3 nursing diagnosis for these priorities. List 3-5 priorities with regards to this patients assessment? Does her medical and surgical history correlate to her present complaint? Please explain? Based on this initial information, what do you anticipate her medical diagnosis will be? Please explain your answer.
Jeanette is a 46-year-old woman who has visited her general practitioner (GP) today, brought in by her husband, Steve, with a 5-day history of nausea, mild abdominal pain and constipation. She decided to see the doctor today, as the pain and nausea were much worse when she woke up this morning and she has vomited twice in the past 3 hours. She also reports her abdomen feels distended and bloated. Jeanette says she had tried to drink more water and eat more fruit and was having bran for breakfast for the past 3 days, as she initially thought she was simply constipated. With the increased generalized abdominal pain and vomiting this morning, she thought she should get a medical opinion. Jeanette has a past medical history of hypercholesterolemia, hypertension, atrial fibrillation and type 2 diabetes mellitus (T2DM) and her BMI is 32 kg/m2. She experienced appendicitis 6 months ago,
for which she had an appendectomy. Her current medications are simvastatin, warfarin, and metformin.
The GP takes her vital signs which are:
• BP – 163/87 mmHg
• HR – 86 beats/minute
• RR – 16 breaths/minute
• T – 36.7°C
• SpO2 – 97% with no supplemental oxygen
Questions:
- What are the points of subjective data we can find in this patient's case?
- What are the points of objective data we can find in this patient's case?
- List your top 3 priorities for this patient.
- Formulate 3 nursing diagnosis for these priorities.
- List 3-5 priorities with regards to this patients assessment?
- Does her medical and surgical history correlate to her present complaint? Please explain?
- Based on this initial information, what do you anticipate her medical diagnosis will be? Please explain your answer.
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