clincals day 5 jim sanderson 1026.docx - Nasogastric Intubation Skills Reasoning Jim Sanderson 65 years old Primary Concept Elimination Interrelated

clincals day 5 jim sanderson 1026.docx - Nasogastric...

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Nasogastric Intubation Skills & Reasoning Jim Sanderson, 65 years old Primary Concept Elimination Interrelated Concepts (In order of emphasis) Clinical Judgment Patient Education Communication Collaboration NCLEX Client Need Categories Percentage of Items from Each Category/Subcategory Covered in Case Study 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% Copyright © 2019 Keith Rischer, d/b/a KeithRN.com. All Rights reserved.
History of Present Problem:Jim Sanderson is a 65-year-old male who is admitted for acute lower abdominal pain which was the result of a ruptured appendix. He had an open appendectomy and is now post-operative day three. He refuses to use the incentive spirometeror get up in the chair and requires encouragement to get out of bed and ambulate on the unit. His appetite is poor, and heeats a small portion of his meals but tolerates and drinks fluids readily. He has had 2200 mL intake to 1800 mL urine output the past 24 hours. He denies nausea and has not had a bowel movement since surgery despite receiving milk of magnesia and senna tabs daily. His abdomen is obese, rounded, firm and tender to palpation with hypoactive bowel sounds. His incision site in his RLQ has no drainage; swelling and mild erythema along the edge of the incision.Current Complaint:Jim puts on his call light. When you arrive, he states he feels nauseated. He has an order for ondansetron 4 mg IV every 4hours PRN for nausea, and this is administered. Thirty minutes later he puts his call light on again, stating that his nauseahas gotten worse. While in the room, he begins to wretch and has a small bile green emesis.What data from the story and current complaint do you NOTICE as RELEVANT and why is it clinically significant?(Reduction of Risk Potential/Health Promotion and Maintenance) RELEVANT Data-Present Problem: Clinical Significance: Lower abdominal pain resulting from ruptured appendix- pt underwent appendectomy. Post op day 3. Noncompliant- will not use incentive spirometer or get up in the chair. Poor appetite. No bowel movement for 3 days. Tender abdomen. incision swelling and mild erythema. After appendectomy it can hurt to breath in deeply or push out air which is likely why pt is unwilling to use incentive spirometer or get up in the chair. Peristalsis does not usually occur until about 3 days after so this is normal and pt should receive an enema. RELEVANT Data-Current Complaint: Clinical Significance: Pt feels nauseated.

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