Nursing Care Plan

Topics: Pain, Liver, Common bile duct Pages: 3 (886 words) Published: April 28, 2013
Mrs. R. T. is a fifty three year-old woman who presented with complaints of nausea, vomiting, and abdominal pain. Patient is married for over thirty years and has three children. Youngest child is twenty three and is in college. Mrs. R.T. stated she finished dinner, at the reception of her oldest daughter’s wedding when the pain began. The pain started mid- epigastric radiating to the back “that just would not go away”. Patient describes this as a “piercing sensation” that was aggravated by eating. History and Physical

Patient admitted to the unit from the emergency department. She is alert and oriented lying in bed, spouse at bedside. Patient is a nonsmoker but states “drinks one or two glasses of wine with dinner daily”. No significant family history noted. Both parents still live. Patient is semi-retired from teaching elementary school. States had a femoral hernia and emergency surgery five years ago. She thought this may be what was going on again. Patient takes a multi vitamin daily and attributed her nausea to the vitamin. Patient states she has lost six pounds in the last couple of weeks, but is not dieting. Physical examination reveals dry mucus membranes; radial pulse tachycardia; skin cold and clammy; normal capillary refill; patient able to grasp my hands weakness noted; basilar crackles without wheezes or rhonchi; a distended abdomen that is very tender on palpation. Bowel sounds are present in all four quadrants, but hypoactive; zero edema noted bilateral lower extremities; skin without redness and intact; bilateral femoral, popliteal and pedal pulses present. Wong baker pain scale used patient states pain in abdomen is a nine out of ten; ten being the worst pain. Ultrasound of gallbladder performed on the patient before arriving on the unit. Patient’s vital signs are; temperature 99.8°F, blood pressure 110/86, pulse 94, and respiratory rate 20. Oxygen saturation is 94% on three liters of oxygen via nasal cannula. Her laboratory...
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