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Write a case study on Acute Health Alteration
Case study of Mrs. Jane Johnston
Mrs. Jane Johnston is 60 years old female patient. She presented with acute abdominal pain from yesterday after having dinner. She has a past surgical history of appendicectomy at the age of 20. She does not drink alcohol. On examination, it was found, T 37.8, PR 96, RR 28, BP 90/60. She complained of sudden upper abdominal pain radiating to back associated with nausea and vomiting. Laboratory investigation revealed Lipase elevated at 2000. A diagnosis of pancreatitis was made.
Part I: Nursing assessment, nursing care, and medical diagnosis
Central Nervous System- Mrs. Jane was conscious and oriented. Her GCS was 15. She was weak, anxious and appeared fatigued. Nausea and vomiting were present. No headache, dizziness, delirium or hallucination noted. On examination her deep tendon reflexes, muscle power, and sensory reflexes were normal. No signs of neck stiffness noted.
Cardiovascular system- Mrs. Jane looked pale, anxious, exhausted and was mildly hypotensive. No cyanosis noted. On examination: BP 90/60 mm of Hg; PR: 96 beats/min, rhythm: regular. On auscultation heart sounds (S1S2) were normal and no murmurs noted. Electrocardiogram revealed normal sinus rhythm.
Respiratory System- Mrs. Jane was noted to be tachypnoeic and she had mild dyspnoea which increased in the supine position. On examination: Respiratory rate: 28 beats/min; rhythm: shallow and rapid respirations. On inspection of the chest, there was equal rise and fall of the chest during breathing. On auscultation of lung sounds, it was found that the left lung had diminished breath sounds with basilar rales present while the right lung had clear breath sounds.
Abdominal Assessment-Mrs. Jane had severe epigastric pain, constant, deep, boring in nature and radiating to back. The pain worsened in the supine position and on eating or drinking. She had dyspepsia and nausea with 3-4 episodes of vomiting.
- Inspection: On inspection, Mrs Jane was noted to have a generalised abdominal distension. Muscular guarding was noted over the upper abdomen. There was an old surgical scar mark of appendicectomy over right lower quadrant. The slight bluish discoloration was noted around the umbilical region- Cullen’s sign positive.
- Auscultation: On auscultation, hypoactive bowel sounds were noted over abdomen with some sluggish movements heard in the lower abdomen.
- Palpation: On palpation, there was severe tenderness in the epigastric region. Mild rigidity was noted over the abdomen. No rebound tenderness was elicited.
Renal assessment- Mrs Jane had dark coloured urine with mild oliguria. There was mild oedema in bilateral lower feet. No periorbital puffiness noted.