Question

A 30-year female comes in complaining of nausea and vomiting x1 week. Client has flu like...

A 30-year female comes in complaining of nausea and vomiting x1 week. Client has flu like symptoms. Client has been taking Midol 2 tablets q4h and Dayquill 2 tablets q4-q6h for the past week. Vital signs: BP 96/58, HR 119, RR 20, T 99.0, and 02 saturation 95% on room air. Client complain of pain 5/10 and it is an aching right upper quadrant pain.

History:No PMH

Family History: Father (DM & HTN), Mother (Stroke), Paternal Grandparents (DM, HTN, HLD, Stroke)

SurgicalHistory:None

Medication:None

Allergy:None

Case Study Questions:

  1. What additional information do I need from this client?
  2. What is the client’s diagnosis?
  3. What is the priority nursing care?
  4. What clinical manifestations will I see on physical examination?
  5. What labs and diagnostic testing will be done? Give rationale for each lab & test.
  6. What are my nursing interventions? Give rationale for each intervention.
  7. What is the disposition?
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Answer #1

1.The additional information which requires is

A. In physical examination -murphy's sign - after  placing hand on the right upper quadrant region and ask the patient to    breath deeply then the patient will experiance pain if she has cholecystitis

B. Blood test - total blood count

C.Abdominal ultrasound or C.T scan report

D. Food habbits.

2. Her signs and symptoms shows acute cholecystitis.

3. Nursing care - provide adequate rest

- pain management

- maintain fluid and electrolyte balance by recording intake and output .

4. On Physical examination - positive murphy's sign will be present :- place the hand on the right upper quadrant and ask the patient to deep breathly then the patient will experiance pain .

- flu like symptoms .

- nausea and vomitting

-leucocytosis

5. Blood test -total blood count in that elevated white blood cell and elevated c-reactive protein level indicate infection.

-High bilirubin level when gallstones partially or completely obstruct bile flow .

- Abdominal ultrasound or CT scan - in that images of gall bladder may reveal signs of cholecystitis

- HIDA scan ( hepatobiliary iminodiacetic acid scan ) to diagnose problems of gall bladder.

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