1020L UNIT FOUR Case Scenario Project Nursing Care Plan Development- Individual Assignment REMEMBER: SBAR = (SITUATION, BACKGROUND, ASSESSMENT, AND RECOMMENDATION) Aurora Dawn (AD). is a 78-year-old woman who is presented to the emergency department (ED) with nausea and vomiting (N/V) and epigastric and left upper quadrant (LUQ) abdominal pain for the last three (3) days. For the last 24 hours, AD experience S epigastric that is severe, sharp, and radiates through to her mid-back. Chief Complaint: "I'm having abdominal pain that woke me up last night and will not go away." The following labs were ordered and obtained in the Emergency Room (ER): CBC with diff, Chem 14, U/A & UCx. Diagnostic Exams: CT scan of Abdomen w/wo contrast AD is divorced, department store sales manager who smokes a half-pack of cigarettes daily. AD has no primary care provider (PCP) and hasn't seen a physician "in years". Denies any B past medical conditions, "don't take any medications", denies alcohol consumption, and use herbal remedies resides in a senior citizens community. Allergies: NKA. ER nurse reported: that AD is anxious and demanding. Last set of vital signs were at 1800: Temp: 100.2 F (sensor, skin), Pulse: 97 (strong, irregular); Respirations -30 (shallow, rapid); Bp-100/70 (Sitting, Left Arm); Initial Sp 02 88% on room air, improved to 92% on 2 L of oxygen by nasal cannula (NC). She is in normal sinus rhythm. She will be admitted to the hospitalist service. Admitting diagnosis is Acute Pancreatitis of unknown etiology. Computed tomography (CT) scan has been ordered, but, unfortunately, the CT scan machine is down and won't be fixed until morning. However, an ultrasound of the abdomen A was performed. Admission labs have been drawn; a clean-catch urine specimen was sent to the lab, and the urine was dark in color. The patient is NPO. 1 Liter Bolus of LR given at 0830. Peripheral IV in Left lower arm with DSLR @ 110 mL/hr; since 0900. Last voided in ED at 1745, total output 890 ml of dark amber urine. Medicated @1600: Morphine 1 mg IVP, Protonix 40 mg IV, and Bentyl 10 mg IM (Left vento-gluteal) Admission Laboratory Test Results Lipase 5000 units/L Amylase 3000 units/L Alk phos (ALP) 350 units/L ALT (SGPT) 90 units/L AST (SGOT) 150 units/L Total bilirubin 2.0 mg/dL Albumin 3.0 g/dL BUN 30 mg/dL Creatinine 1.4 mg/dL WBC 20,500/mm Diagnostic Exam Results CXR -The admission chest x-ray (CXR) report reads, "small pleural effusion in the left lower lobe (LLL)" ABD-Ultrasound-"no cholelithiasis, gallbladder wall thickening, or choledocholithiasis was seen. The pancreas was not well visualized due to overlying bowel gas."Arrived to Med/Surg unit at 1930 Admitting Assessment: General Survey: Patient appears restless and lying on her right side in a semi-fetal position. 5 ft 7 inch tall, 196 lb elderly black female. Arrive to floor with daughter. Vital Signs: Temp: 99.8 F (oral), Pulse: 110 (strong, irregular), Resp: 32 (rapid, guarded), BP: 122/84 (laying, left arm), O2 sat: 90% on 2 L O2/NC, Pain Scale 10+/10 Skin: Skin is cool, diaphoretic, and pale with poor skin turgor Neuro: Alert, awake and oriented to person, place and time. PERRLA. HEENT: Oral mucosa dry, pink, and pasty. No JVD, No Bruits auscultated Thorax: $1, $2 regular. Apical pulse 120 strong, irregular. Respirations 30 equal chest rises, rapid, and unlabored. Breath sounds are absent in lower left lobe (LLL) posteriorly otherwise, clear to auscultation throughout. Abd: Complains of nausea and is having dry heaves. Bowel sounds are hypoactive. Abdomen is distended, firm, and tender in a diffuse fashion to light palpation, with guarding noted. Last bowel movement: yesterday. GU: No discharge or odor noted. Extremities: Peripheral pulses are faintly palpable in four extremities. Upper and lower with full ROM's. Ambulates with assistance. Psychosocial: Lives with Pierre, her boyfriend for last 3 years in retired community, has many friends and is active within her community and church. Has three children (2 daughters and one son) lives near the patient community. Admits to drinking \"3 or 4 scotch- on-the-rocks\" daily. Smokes cigarettes. Develop a plan of care for this patient. Aurora Dawn 78yr old Female D.O.B. 11/28/1944 a ~~ Miia, en us anana4 Please check the appropriate sent signature BOX: DOCTORS ORDERS ALLERGIES: PCN Today 0400 Admit to Med/Surg Unit Service: Dr. Alba Pain DX: acute pancreatitis Hx: Current smoker Condition: Guarded VS: Q4H Activity: As tolerated Code Status: Full resuscitation Diet: NPO Strict 1/O Daily CBC and BMP, Lipase and Amylase, LFT Peripheral IV access 02 2 L n/c Daily CBC and BMP, Lipase and Amylase, LFT I/V Fluids D5LR@ 110 ml/hr Morphine 1 mg IV Q4H PRN for Moderate to Severe pain Bentyl 10mg IM Daily Protonix 40 mg IV daily Tylenol suppository 650 mg per rectum Q6H PRN for mild pain and fever above 100.4 F Aurora Dawn 78 yrs old Female D.O.B. 11/28/1944 MR # 02000566