Background Information
Review the case study below. Analyze the data and answer the questions. You must use at least 2 scholarly references to support your answers to the questions.
Phillipe is a 36-year-old migrant worker male who presents at the free clinic with complaints of upper abdominal pain which has been gradually getting worse in the past month. He states the pain is burning (like eating hot tamale peppers) and points to the epigastric region. Jose has been drinking milk and taking antacids in the past but in the last day has had no relief. His current pain level is 9 on a 10 scale. He states his pain does not radiate and denies any nausea or vomiting. He laughs stating his appetite is great.
He states he has been taking ibuprofen twice a day for knee pain for about the last year. He also takes a baby aspirin daily because he heard it is good for the heart. Jose smokes about a pack, to a pack and a half, of cigarettes daily. He drinks beer on the weekends and special occasions. He estimates that he drinks about one 12 pack a week. He is allergic to meperidine.
Lately, he has been tired and admits to feeling stressed since work is slowing down and he supports his wife and 4 children on his wages. He is supposed to be taking Vasotec for his blood pressure but ran out of pills a month ago and could not afford to get a refill.
The nurse notes his temp is 98.8 F, his pulse is 90 and respirations 28. BP is 156/98, weight 225 lb and height 53 He appears to be in pain but does not seem to be guarding when the abdomen is palpated. He has no insurance and gets his medications from the clinic. The nurse notes his extremities appear edematous and he has a nonproductive cough on exertion.
Instructions
Review the rubric to make sure you understand the criteria for earning your grade.
Read in your textbook, Physical Examination and Health Assessment, chapter 22, “Abdomen.”
Prepare and develop an SBAR communication, using the CASE STUDY TEMPLATE (found in the instructions) based on the above data. You will note that you have data for the first two areas of the communication tool. Utilize questions a, b, and c below as you address the assessment component. Utilize questions d and e as you develop the recommendations.
What focused assessments would you perform on Phillipe? What cues are you looking for and why? (Utilize at least one scholarly reference for rationale.)
What problems would you deduce? What do you believe is happening to Phillipe? How severe are the problems? (Prioritize according to labels on page 5 of the text.)
Utilizing NANDA diagnostic labels, identify 3 nursing diagnoses.
Based on the data, develop 3 goals. (Goals must be SMART.)
What recommendations do you have? What are some probable interventions you would recommend based upon the assessment data and goals? Define the assessment data and evidence-based prior knowledge upon which you are basing your recommendations. (You must have at least 3 recommendations and use at least 2 scholarly references.)
Research and select at least two current scholarly sources to support your explanations and insights.
Last Completed Projects
| topic title | academic level | Writer | delivered |
|---|