Question

A focused assessment on M.S. reveals the following B/P 120/74, HR= 110, RR=24, Temp. 100.4 degrees F. Abdomen firm and slightly distended. High pitched bowel sounds in upper quadrants. No bowel sounds auscultated in left lower quadrant. Mild palpation elicits pain. Questions: Which physical assessment findings are of most concern to you? Based upon the objective and subjective data presented to you, what would be the priority nursing diagnoses? What diagnostic studies do you think may be ordered for MR. M.S.?

Answer 1

The primary concern is pain and hyperthermia(temperature-100•F)

NURSING DIAGNOSIS

• acute pain related to abdominal distention and increased peristalsis
• Hyperthermia related to disease condition
• Constipation related to absence of bowel movement in the left lower quadrant

DIAGNOSTIC STUDIES

1. History collection
2. Physical examination
3. Imaging studies-CT scan,X-ray
4. Visualization of colon by colonoscopy and sigmoidoscopy
5. Blood test-CBC and blood chemistries(WBC,HAemoglobin,Hematocrit concentration)
6. Serum electrolytes,BUN,creatinine concentration