files (1)reflection.docxreflection.docx
1. Completes reflective journal
0. 150 word minimum reflection.
0. Summarizes new information learned by completing this assignment.
0. Reflects on how the new knowledge will impact future behavior as a healthcare professional.
0. Logical reflective flow which follows standard grammatical rules with minimal (1-2) misspellings and APA where applicable
1. Completes reflective journal
1. 150 word minimum reflection.
1. Summarizes new information learned by completing this assignment.
1. Reflects on how the new knowledge will impact future behavior as a healthcare professional.
1. Logical reflective flow which follows standard grammatical rules with minimal (1-2) misspellings and APA where applicable
NURSING ASSESSMENT & NOTES
06/06 2100
Neuro/Cognitive: Alert and oriented to person, place, time, and situation.
Gastrointestinal: BS present x 4 quadrants. Abdomen diffusely tender, distended. Last bowel movement x 1 day ago. ?????. Bilious colored emesis. Rates 9/10 constant epigastric pain.
06/06 2105
Situation: Ms. Sigmund is in room 5. She just checked in, and I performed her assessment. She is vomiting up bilious emesis about every 5 minutes. She is reporting 9/10 abdominal pain located in the epigastric region.
Background: Ms. Sigmund is a 39-year-old female with a history of alcohol abuse and gallstones. She is a current everyday smoker.
Assessment: Her abdomen is distended and tender. She has a fever of 101.1°F. Other vital signs are all normal.
Recommendation: I am requesting a prescription for pain and nausea medicine. I would like you to see the client as soon as you can step away.
06/08 0700 Nursing Note: Assumed care of client. Client lying down with HOB 30 degrees. Client is agitated and febrile. Alert and oriented to person and place. Client is reporting excessive thirst. Urine output 325 mL over past 24 hours. Tachycardia and tachypnea present. Breath sounds clear to auscultation. Blood pressure is hypotensive. Client rates pain at 9/10.
VITAL SIGN TREND
Date
Temp
HR
RR
BP
SpO2
O2
06/06 2100
101.1°F (38.4°C)
90
22
118/78
96%
RA
06/06 2105
101.5°F (38.6°C)
99
20
116/76
96%
RA
06/08 0700
100.8°F (38.2°C)
106
24
90/60
96%
RA
2100
Client Information:
Medical history: Appendicitis, cholelithiasis
Surgical History: Appendectomy
Social History: 6-pack of light beer every night, 1.5 pack/day cigarette smoker. Occupation as a hairstylist. Divorced with no children.
Family history:
· Mother, deceased ?? pancreatic cancer
· Father, living ?? estranged, medical history unknown
· Brother with chronic pancreatitis
· Sister with Type 2 diabetes, obesity
LAB RESULTS
Lab
Normal
Result – 06/06 2115
Result – 06/08 0600
Lipase
<95 mm3
480
475
ALT
0-35 mm3
21
20
AST
0-35 mm3
18
19
GGT
0-30 U/L
29
25
Bilirubin
0.3-1.2 mg/dL
1.0
14
Blood Cultures
Negative
Negative
N/A
CRP
<1.0 mg/dL
5
10
WBC
4,000-10,000 mm3
14,568
17,699
RBC
4.2-5.9 cells/L
4.5
4.9
HG
12-17 g/dL
15
16
HCT
36-51%
60%
80%
DIAGNOSTIC TEST RESULTS
Date
Diagnostic Test
Findings
06/06 2135
Abdomen CT
Homogenously enlarged pancreas. Peripancreatic fluid collection noted.
Impression: Acute interstitial edematous pancreatitis.
PROVIDER PRESCRIPTIONS & NOTES
06/06 2105
Prescriptions:
· STAT serum lipase
· STAT serum ALT, AST, GGT, and bilirubin
· STAT serum CRP
· STAT CBC
· STAT CT abdomen
· Blood cultures x 2
· Diet: Nothing by mouth, except meds
· Place nasogastric tube to low intermittent suction
· Peripheral IV start
· 0.9% NaCl IV infusion 125 mL/hr
· Acetaminophen 500 mg as needed by mouth every 4 hours for fever and mild pain
· Morphine 2 mg IV as needed every 4 hours for pain
· Ondansetron 4 mg IV as needed every 6 hours for nausea
MEDICATION ADMINISTRATION RECORD Medication Date Staff initals Acetaminophen
Dose: 500 mg
Route: By mouth
None given in past 24 hrs Morphine
Dose: 2 mg
Route: IV 06/08 0600 SAD Ondansetron
Dose: 4 mg
Route: By mouth06/08 0600 SAD
Your answer is correct.
Debriefing: Risk factors for pancreatitis include smoking, excessive alcohol consumption, genetics and family history of pancreatic disorders, abdominal trauma, endoscopic retrograde cholangiopancreatography, diabetes, obesity, and gallstones. The client is not classified as obese due to her BMI, her occupation as a hairdresser does not increase her risk, and she does not have a diagnosis of diabetes. The appendectomy is an example of abdominal trauma, but it is not current.
Consider:
1. What diagnostic tests are used to diagnose acute pancreatitis?
2. Describe the functions of the exocrine pancreas.
3. Which of these risk factors are modifiable? Which are non-modifiable?
The correct answers are:
Smoking
Alcohol Use
Family History
Gallstones
Your answer is correct.
Debriefing: Diagnostic tests to check the liver, gallbladder, pancreas are useful to identify a diagnosis. The CBC can indicate infection/inflammation. A head CT, chest x-ray, and kidney ultrasound would not be helpful diagnostics based on the client??s medical exam and clinical presentation.
Consider:
1. Which results can help differentiate pancreatitis, cholecystitis, and gastritis?
2. What is the difference between conjugated and unconjugated bilirubin?
3. What endoscopic procedures might be prescribed for this client?
Your answer is correct.
Debriefing: The nurse??s priority would be addressing the client??s hypotension. The nurse would not give anything by mouth due to the client??s NPO status. Oxygen administration is not indicated since the client??s O2 saturation is normal.
Consider:
1. What should the nurse anticipate the health care provider will prescribe to address the blood pressure?
2. What are the signs/symptoms of hypotension?
3. What would be the next priority after managing the blood pressure?
The correct answer is:
The nurse must [call the physician] because of [blood pressure].
reflection.docx
1. Completes reflective journal
0. 150 word minimum reflection.
0. Summarizes new information learned by completing this assignment.
0. Reflects on how the new knowledge will impact future behavior as a healthcare professional.
0. Logical reflective flow which follows standard grammatical rules with minimal (1-2) misspellings and APA where applicable
1. Completes reflective journal
1. 150 word minimum reflection.
1. Summarizes new information learned by completing this assignment.
1. Reflects on how the new knowledge will impact future behavior as a healthcare professional.
1. Logical reflective flow which follows standard grammatical rules with minimal (1-2) misspellings and APA where applicable
NURSING ASSESSMENT & NOTES
06/06 2100
Neuro/Cognitive: Alert and oriented to person, place, time, and situation.
Gastrointestinal: BS present x 4 quadrants. Abdomen diffusely tender, distended. Last bowel movement x 1 day ago. ?????. Bilious colored emesis. Rates 9/10 constant epigastric pain.
06/06 2105
Situation: Ms. Sigmund is in room 5. She just checked in, and I performed her assessment. She is vomiting up bilious emesis about every 5 minutes. She is reporting 9/10 abdominal pain located in the epigastric region.
Background: Ms. Sigmund is a 39-year-old female with a history of alcohol abuse and gallstones. She is a current everyday smoker.
Assessment: Her abdomen is distended and tender. She has a fever of 101.1°F. Other vital signs are all normal.
Recommendation: I am requesting a prescription for pain and nausea medicine. I would like you to see the client as soon as you can step away.
06/08 0700 Nursing Note: Assumed care of client. Client lying down with HOB 30 degrees. Client is agitated and febrile. Alert and oriented to person and place. Client is reporting excessive thirst. Urine output 325 mL over past 24 hours. Tachycardia and tachypnea present. Breath sounds clear to auscultation. Blood pressure is hypotensive. Client rates pain at 9/10.
VITAL SIGN TREND
Date
Temp
HR
RR
BP
SpO2
O2
06/06 2100
101.1°F (38.4°C)
90
22
118/78
96%
RA
06/06 2105
101.5°F (38.6°C)
99
20
116/76
96%
RA
06/08 0700
100.8°F (38.2°C)
106
24
90/60
96%
RA
2100
Client Information:
Medical history: Appendicitis, cholelithiasis
Surgical History: Appendectomy
Social History: 6-pack of light beer every night, 1.5 pack/day cigarette smoker. Occupation as a hairstylist. Divorced with no children.
Family history:
· Mother, deceased ?? pancreatic cancer
· Father, living ?? estranged, medical history unknown
· Brother with chronic pancreatitis
· Sister with Type 2 diabetes, obesity
LAB RESULTS
Lab
Normal
Result – 06/06 2115
Result – 06/08 0600
Lipase
<95 mm3
480
475
ALT
0-35 mm3
21
20
AST
0-35 mm3
18
19
GGT
0-30 U/L
29
25
Bilirubin
0.3-1.2 mg/dL
1.0
14
Blood Cultures
Negative
Negative
N/A
CRP
<1.0 mg/dL
5
10
WBC
4,000-10,000 mm3
14,568
17,699
RBC
4.2-5.9 cells/L
4.5
4.9
HG
12-17 g/dL
15
16
HCT
36-51%
60%
80%
DIAGNOSTIC TEST RESULTS
Date
Diagnostic Test
Findings
06/06 2135
Abdomen CT
Homogenously enlarged pancreas. Peripancreatic fluid collection noted.
Impression: Acute interstitial edematous pancreatitis.
PROVIDER PRESCRIPTIONS & NOTES
06/06 2105
Prescriptions:
· STAT serum lipase
· STAT serum ALT, AST, GGT, and bilirubin
· STAT serum CRP
· STAT CBC
· STAT CT abdomen
· Blood cultures x 2
· Diet: Nothing by mouth, except meds
· Place nasogastric tube to low intermittent suction
· Peripheral IV start
· 0.9% NaCl IV infusion 125 mL/hr
· Acetaminophen 500 mg as needed by mouth every 4 hours for fever and mild pain
· Morphine 2 mg IV as needed every 4 hours for pain
· Ondansetron 4 mg IV as needed every 6 hours for nausea
MEDICATION ADMINISTRATION RECORD Medication Date Staff initals Acetaminophen
Dose: 500 mg
Route: By mouth
None given in past 24 hrs Morphine
Dose: 2 mg
Route: IV 06/08 0600 SAD Ondansetron
Dose: 4 mg
Route: By mouth06/08 0600 SAD
Your answer is correct.
Debriefing: Risk factors for pancreatitis include smoking, excessive alcohol consumption, genetics and family history of pancreatic disorders, abdominal trauma, endoscopic retrograde cholangiopancreatography, diabetes, obesity, and gallstones. The client is not classified as obese due to her BMI, her occupation as a hairdresser does not increase her risk, and she does not have a diagnosis of diabetes. The appendectomy is an example of abdominal trauma, but it is not current.
Consider:
1. What diagnostic tests are used to diagnose acute pancreatitis?
2. Describe the functions of the exocrine pancreas.
3. Which of these risk factors are modifiable? Which are non-modifiable?
The correct answers are:
Smoking
Alcohol Use
Family History
Gallstones
Your answer is correct.
Debriefing: Diagnostic tests to check the liver, gallbladder, pancreas are useful to identify a diagnosis. The CBC can indicate infection/inflammation. A head CT, chest x-ray, and kidney ultrasound would not be helpful diagnostics based on the client??s medical exam and clinical presentation.
Consider:
1. Which results can help differentiate pancreatitis, cholecystitis, and gastritis?
2. What is the difference between conjugated and unconjugated bilirubin?
3. What endoscopic procedures might be prescribed for this client?
Your answer is correct.
Debriefing: The nurse??s priority would be addressing the client??s hypotension. The nurse would not give anything by mouth due to the client??s NPO status. Oxygen administration is not indicated since the client??s O2 saturation is normal.
Consider:
1. What should the nurse anticipate the health care provider will prescribe to address the blood pressure?
2. What are the signs/symptoms of hypotension?
3. What would be the next priority after managing the blood pressure?
The correct answer is:
The nurse must [call the physician] because of [blood pressure].
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