Nursing Health history

To nurses and medical students, the book by Carolyn Jarvis is important as it contains a variety of texts that is pivotal in the treatment as well as accessing of patients. The text is instrumental in accessing various problems that the patient might be encountering in their lives as far as their health is concerned. The book contains various assessments of the parts of people’s body, which is important in enlightening people on the various parts of their bodies and the causes of pains they may be undergoing through. The assessment, especially on the abdominal pains is essential in critical thinking of the student.

A description is given of a patient with an age of 38 years, and a female. Another important thing to note about the patient is that she is of Hispanic origin. Though the patient is learned and a graduate in criminal justice, it is notable that she is not employed. When it comes to the marital status, it is also notable that the patient is single. The complaint that the patient has is notably abdominal pain. According to Saunders, there are several causes of abdominal pains among women. It is not always obvious that the pain is caused by complications in the abdomen that there are abdominal pains experienced due to the neighboring organs. Pain may also be due to the organs close to the abdomen, for example from such parts of the body like the kidney (Jarvis, 2008). The only way to be sure is clear assessment if the patient and also looking back to the clinical history of the patient. The age of the patient is also an important consideration as young females who are not of the age of bearing children tend to have different causes of pain from the ones who are in the age of bearing children. In this scenario, at the age of 38, the patient is in the age of bearing children. At this age, there is a likelihood of the patient suffering due to such complications that occur to women who are in child bearing period.

History of present illness

According to the patient, the illness started for days ago. The pain in the abdomen is achy and also cramping. There are also incidents of nausea as well as vomiting. It is also notable there rare no incidents of diarrhea and also lying on the side minimizes the pain that is being experienced.

Medical history

The patient has a notable past medical history of smoking regularly; the parents of the patient are also notably dead. The patient has two brothers and two sisters; the number is similar when it comes to children as she has two children. Socially the patient is good with people and she also finds time to get involved with other people, especially her friends. The patient is also notably involved in social occasions, especially the ones that involve the environment around her. Sexually, the patient has for the recent years not been in a stable relationship. After she broke up with the father of her children, she took it upon herself to cater for her children and in turn, she has no time to be involved in sexual relationships.

Review of Systems

The most effective thing of distinguishing the organic and the non-organic causes of pain are history and examination of the patient. The history of the patient is notably the most important thing in the diagnoses of the patient. It is after the review of both the objective and subjective information that the right medication is likely to be prescribed for the patient. Subjective information: the Pt was voidable after sometimes the vomiting seemed to decline as well as nausea. Objective information: the stomach tended to be soft and also non tender. Bowel sounds were evident in the four quadrants, flatus were also evident in this scenario. Further, the patient had notable ten pound loss after admission in the hospital.

Nursing DX

The DX information is important ensuring that the patient gets the right diagnoses. In this case, the DX can be painful discomfort: achy abdomen discomfort caused due to UTI. The four quadrants should be accessed to determine which one of them is problematic. Only after the lab testing that the problem can be resolved. The assessment exercises that the nurses usually should carry out in this case include the following. Accessing the health history of the patient, performing physical examination, accessing the ADLs that are present in the patient, reviewing the signs, the symptoms, and complications according to the medical condition are th4 ways the nurse should follow in accessing the patient. Finally, there is reviewing of the conditions and the treatment the patient is undergoing. Much can be learnt through this exercise, when it comes to the symptoms the crampy pain experienced by the patient can be the main cause of vomiting as vomiting relieves it.

Plan

The main goals of this assessment are to get the main cause of the pain which the patient is experiencing. Through critical thinking and judging by the symptoms the patient is experiencing, the cause of the pain is going to be revealed in this particular exercise. Also notable is the fact that the interventions needed in ensuring that the pain does not persist will also be accessed and determined again through critical thinking.

After the return of the results of the tests done on abdominal cramping, nausea and vomiting, the fact that the complains by the patient are some what subjective. It is important for the nurse to get to know whether the symptoms after the diagnoses are in existence and if such are in existence they should be reported. Since the patient is vomiting, there is the risk that the patient is likely to be dehydrated. In turn, there will be a likelihood of a fluid imbalance that will case electrolyte imbalance in the intestine due to the blockage of hydrochloric acid and potassium. In an attempt to restore the lost balance of fluids that is not in existence, the patient must be orally involved in replacing the fluids. The nurse should keep monitoring the progress of the patient to ensure that the metabolism needs are met (Cox, 2009). Another way of minimizing abdominal distention that may be in existences is by encouraging the patient to be ambulant so as to expel flatus that she may be having.

The evaluation of the patient will also be a means of getting the right diagnosis of the patient, and also observance of the success achieved in this particular exercise. Through observance by the nurse, tests needs to be carried out to ensure that there is improvement of the health of the patient. Also inclusive is asking of questions by the nurse of the feeling the patient is encountering at that particular point after the medication is commissioned.

Summary

            As the symptoms revealed by the patient are keen to note the problem that the patient is experiencing is being brought out by excessive pain in the abdomen section. Though there are so many causes of pain in this section of the body, accessing in detail the pain section is an important tool in knowledge of the cause. According to the description of the patient, the symptoms tend to favor the pancreatitis as the main cause of the pain. However, this can not be summed up to be the way to go as medication is considered as tests have to be carried out to determine the true cause of the pain. Using the right review question is considerably the best way to ensure that the right medication is reached at. However, it is notable that the right intervention measures have to be arrived at when the problem has been found out. Having the medication prescribed also calls for observance by the nurses of how the patient is responding to the treatment as different people respond to treatment differently. If incase there are no  visible changes of success that is achieved due to the medication, there is need to get some more tests done to ensure that the real cause of the problem is reached at. In this case, the problem is abdominal pain. Through accessing the symptoms laid down by the patient, the treatment is easily likely to be reached at. There are no conceivable barriers to the carrying out of the testing as the patient though Hispanic is learned.

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