Question

I.             Developing Nurse Thinking by Identifying Clinical Relevance/Significance

History of Present Problem:
Abdi Khalid is a 27-year-old male who presents to the emergency room with complaints of abdominal pain and significant distention, intermittent nausea and vomiting with dark flecks present in emesis, and darker than normal urine. He was previously healthy and symptoms began abruptly and increased in severity over the last week. Further observation reveals he is somewhat lethargic, and quickly drifts back to sleep after answering questions. Abdi also has scleral icterus, and pitting edema in bilateral lower extremities. He denies taking any prescription medications for any health problems at home, but states he does use Tylenol and Ibuprofen for occasional joint pain. 

 

Personal/Social History:

Abdi immigrated to the United States from Somalia 3-years-ago. One year ago he was hospitalized in New York City with a “liver problem”, but cannot recall what it was. He is unable to provide any specifics related to the diagnosis, treatment, and follow-up care; however, he does mention it being related to a “virus.” He denies any illicit drug and ETOH use. He states he has smoked 1-pack of cigarettes per day since he was a teenager and states he chewed Khat for several years when in Somalia. 

 

II. Nurse Collected Clinical Data:

Current VS:	PQRST Pain Scale (5th VS)
T: 98.1 F	Precipitating Factors	Initially came on slowly, started as a dull ache in RUQ that increased in intensity and is now a generalized dull ache throughout the abdomen
P: 101	Quality	Dull aching pain
R: 26	Radiation	Started in RUQ → LUQ → now increasing as distention increases
BP: 99/52	Severity	7/10 in severity and is worse after eating
O2 sat: 96% RA	Time	Is constant in nature

Current Assessment:
GENERAL APPEARANCE:	Resting between cares, appears in no acute distress
NEURO:	Somewhat lethargic, awakens to touch. Positive Asterixis. Flat affect. A&O x4
RESP:	Breath sounds diminished and equal bilaterally, slightly labored breathing
CARDIAC:	Warm & dry, 2+ pitting edema, heart sounds regular with no abnormal beats, pulses weak with palpation at radial/pedal/post-tibial landmarks
GI:	+ Bowel sounds, abdomen is firm and distended, diffuse tenderness, slight spleen and liver enlargement palpated.
GU:	Voiding without difficulty, but small amounts, urine is dark brown/amber in color
SKIN:	Skin integrity intact, appears dry with scratch marks present
HEENT:	Atraumatic, icteric eyes, poor dentition

What data from the histories, nurse collected data and vital signs is important & RELEVANT and has clinical significance to the nurse? 

 

RELEVANT Data from Present Problem:	Clinical Significance:
Complaints of abdominal pain Abdominal distention Intermittent nausea and vomiting that has dark flecks in emesis Darker than normal urine Somewhat lethargic Scleral icterus Bilateral lower extremity pitting edema
RELEVANT Data from Social History:	Clinical Significance:
Previous hospitalization for a “liver problem” related to a virus No illicit drug or alcohol use Smokes 1-pack of cigarettes per day since he was a younger teen Chewed Khat for several years
RELEVANT VS Data	Clinical Significance:
P: 101 R: 26 BP: 99/52 Initially slow onset as a dull ache in RUQ, increased in intensity, now general dull ache through abdomen Started in RUQ -> LUQ -> increasing as distention increases Constant aching

Lab/diagnostic Results: What lab results are RELEVANT that must be recognized as clinically significant to the nurse?  

Basic Metabolic Panel (BMP):	Current:	High/Low/ WNL?	Clinical Significance/Why is it occurring?
Sodium (135-145 mEq/L)	150	High
Potassium (3.5-5.0 mEq/L)	2.9	Low
Glucose (70-110 mg/dL)	137	High
Creatinine (0.6-1.2 mg/dL)	2.44	High
BUN (10-31 mg/dL)	51	High
Complete Blood Count (CBC):	Current:	High/Low/ WNL?	Clinical Significance/Why is it occurring?
WBC (4.5-11.0 mm 3)	3.9	Low
Hgb (12-16 g/dL)	10.4	Low
Platelets (150-450x 103/µl)	91	Low
Neutrophil % (42-72)	46	WNL
Liver Function Tests (LFT’s)	Current	High/Low/ WDL?	Clinical Significance/Why is it occurring?
Total Bilirubin (0.2-1.2 mg/dL)	14.0	High
Alkaline Phosphatase (38-126 U/L)	365	High
ALT (10-40 U/L)	414	High
AST (10-30 U/L)	655	High
Albumin (3.5-5.0 g/dL)	2.1	Low
Total Protein (6.4-8.3 g/dL)	4.0	Low
Ammonia (15-45 mcg N/dL)	103	High
INR (<1.2 mg/dL)	2.2	High
Urine Bilirubin	Present	Abnormal
Miscellaneous Labs			Clinical Significance/Why is it occurring?
Hepatitis B virus	PENDING	-----
Hepatitis C virus	PENDING	-----

 

After reviewing the objective, subjective and laboratory data, what conclusions can you make about the type of gastrointestinal problem Abdi is experiencing?  Provide an in-depth rationale for your thinking.   2.5 Points