University:
American Career College
Course:
NURS-113 | Beginning Medical/Surgical Nursing
Academic year:

2019
Views:

73

Pages:

3
Author:

folclord7m

Abdominal Case Study #1 A 55-yr. old Caucasian male presents at the V.A. clinic complaining of abdominal discomfort and swelling of his legs. He states he becomes SOB easily and it is worse when lying down. He states his appetite is normal, smokes 1 ppd and is a drinker. Assessment: VS 164/90, HR 90, RR 20, T 98.4, 02 sat 92%. Pt. extremities are thin with 3+ edema of bilateral legs, abdomen distended, JVD present. Hum to the left of the aorta. 1. Normal Subjective data: ( 6 pts.)  Appetite is normal 2. Abnormal Subjective data: ( 6 pts.)  Smokes 1 ppd  A drinker  Complaining of abdominal discomfort  Complaining of swelling in legs  States he becomes SOB easily, and worse when lying down 3. Normal Objective data: (6 pts.)  55 year old Caucasian male  HR 90  RR 20  T 98.4 4. Abnormal Objective data: ( 6 pts.)  VS 164/90  O2 sat 92%  Patient extremities are thin within 3+ edema of bilateral legs  Abdomen distended  JVD present  Hum to the left of aorta 5. Disease process: (6 pts.)  Liver failure/ Portal Hypertension 6. Health history: ( 30 pts.)  Do you have history of cirrhosis, or scarring of the liver?  Do you have Hepatitis B  How long have you been drinking alcohol?  Do you have gastrointestinal bleeding?  What color is your stool?  Do you have a hard time passing stool?  Do you currently take any medications?  How much alcohol do you drink per day?  Can you describe your abdominal pain? What is the intensity of your pain?  How many calories are you consuming per day?  Do you get nausea, or do you vomit after eating?  When did you notice the swelling in your legs?  When did you notice your shortness of breath?  When did your stomach discomfort first begin?  How long have you been smoking? 7. Physical Assessment  Assess patients skin turgor  Inspect, auscultate, percuss and palpate the abdomen  Blood test to assess for thrombocytopenia  Assess skin for spider angioma  Assess patients skin color and sclera of eyes for indications of jaundice.  Assess for pallor which would indicate internal bleeding  Assess for swollen vein (varices) within umbilical area (belly button), stomach, rectum, esophagus  Assess for ascites  Assess for murmurs over pericardium  Assess breathing for mild heaves  Assess patients affect for hints of guarding during palpation of abdomen  Assess for re-bound tenderness  Assess for cyanosis  Assess for Encephalopathy  Assess patients mental state for confusion and LOC that could occur from poor liver function due to the diversion of blood flow away from the liver.