Nurse’s Note: DOB: 06/02/19XX 0645: 45-year-old…
Nurse’s Note: DOB: 06/02/19XX 0645: 45-year-old male c/o nausea/vomiting and severe flank pain that radiates into his groin for the last 5 days. Patient states pain is not constant but comes in waves like he is being stabbed with a knife. He states his dad had an attack like this last year and had to have surgery. He has been working outdoors in high heat and humidity the last week doing construction. Past medical history includes hyperparathyroidism, HTN, DM, obesity, Vitamin D deficiency. Physical Assessment findings A&O X4, skin hot and dry with dry mucous membranes, patient sitting in chair holding his side with facial grimace and intermittent moaning. Tenting noted to skin. He is holding a kidney basin with 50 ml of green emesis. Nurse’s Note: 0730: Patient reports increased frequency with urination. V.S. 101.2, 95 bpm, 20 RR, 162/84, O2 saturation 98% on RA. Patient has voided 150 ml. of dark amber urine. A urinalysis was ordered. The urinalysis confirmed the sample was positive for blood, nitrates and leucocyte esterase. The patient is admitted with a diagnosis of Renal Calculi, r/o Urinary tract infection. 0800 The patient has been admitted to your unit with the following Orders: NPO Place 20g IV I&O Activity as tolerated IV 0.9 NS at 125 ml/hr Urinalysis Blood Chemistries IV Morphine 2mg IV Q4hrs for pain Non-contrast CT scan Strain all urine Sulfamethoxazole/Timethoprim 250mg IV q6 hours Nurse’s Note 0935: Upon entering the patient’s room, this RN found patient doubled over in pain and guarding his abdomen. Patient rates pain 10/10. Upon assessment, patient is diaphoretic with vital signs as follows: 102.4, 125 bpm, 32 RR, 98/62, O2 saturation 95% on RA. Patient continues to c/o nausea. CT Scan: Obstructing stone located in patient’s ureter measuring 6mm. Nurse’s Note 1000: Physician notified of patient’s condition. New orders received: bolus of IV 0.9% NS, PR Acetaminophen, IV Zofran, IV pain medication and repeat non-contrast CT. Physician ordered for urology consult. Phone called placed to on-call physician, provider aware. Patient awaiting urologist arrival to the floor. What assessment findings do we need to complete in order to determine the effectiveness of the physician’s orders? Select all that apply.
Read Details