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History and Physical Client admitted to the medical-surgical unit with severe, acute abdominal pain, abdominal distention, diarrhea, mucus and small amount of blood in the stool, and a 12% weight loss over the past 2 months. Client’s weight 2 months ago was 100.3 kg (221.1 lb). Client has a history of Crohn’s disease and a seizure disorder that is managed with diet and medication. Respirations are equal and unlabored. S1S2 heart tones auscultated. Abdominal assessment performed with muscle guarding and tenderness in the right lower quadrant noted on palpation. Abdomen is firm and rigid upon examination. Abdominal pain rated as an 8 on a scale of 0 to 10. Client states that pain is constant and localized in the lower right abdominal quadrant. Reports anorexia. Hypoactive bowel sounds noted upon auscultation. Vital Signs Day 1 0700: Temperature 38.5° C (101.4° F) Heart rate 102/min Respiratory rate 18/min Blood pressure 136/78 mm Hg Oxygen saturation 97% on room air Laboratory Results Day 1: Hgb 12 g/dL (12 to 168 g/dL female) Hct 34% (37% to 4752% female) WBC count 19,000/mm³ (5,000 to 10,000/mm³) Neutrophils 75% (55% to 70%) Erythrocyte sedimentation rate (ESR) 18 mm/hr (less than 15 mm/hr) Medication Administration Record Day 1: Phenytoin 200 mg PO daily The nurse has completed the assessment and is reviewing the findings in the EMR. Click to highlight the findings that require follow-up. To deselect a finding, click on the finding again. History and Physical: Client admitted to the medical-surgical unit with severe, acute abdominal pain, abdominal distention, diarrhea, mucus and small all amount of blood in the stool, and a 12% weight loss over the past 2 months. Client’s weight 2 months ago was 100.3 kg (221.1 lb). Client has a history of Crohn’s disease and a seizure disorder that is managed with diet and medication. Respirations are equal and unlabored. S1S2 heart tones auscultated. Abdominal assessment performed with muscle guarding and tenderness in the right lower quadrant noted on palpation. Abdomen is firm and rigid upon examination. Abdominal pain rated as an 8 on a scale of 0 to 10. Client states that pain is constant and localized in the lower right abdominal quadrant. Reports anorexia. Hypoactive bowel sounds noted upon auscultation. Day 1 1700: Temperature 38.5° C (101.4° F) Heart rate 102/min Respiratory rate 18/min Blood pressure 136/78 mm Hg Oxygen saturation 97% on room air
SCIENCE
HEALTH SCIENCE
NURSING

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