Question

Mr. McClaren is a 48-year-old man who is admitted to the emergency department (ED) with abdominal pain and general weakness. He reports that he drinks “one bottle of scotch whisky every week for the past one year, and one to two cans of beer during the weekends.” For the past three months, his condition has started to deteriorate. His wife claims that “he has not been eating well for the past three months”. Mr. McClaren reports he has passed dark red stool on three occasions – the last one being just one day before coming to ED. On examination, Mr. McClaren has an enlarged abdomen with tenderness upon palpation. He also presents with the following clinical manifestations: peripheral edema, pale yellow skin color, dry mucus membranes and body weakness. The physician suspects that Mr. McClaren has hepatic cirrhosis. His vital sign findings include: Temperature 37.8 Celsius, BP 94/52, Pulse 110, Oxygen saturation 94%. From your nursing classes, you know that some of the treatments Mr. McClaren may receive are paracentesis, ultrasound and CT scan of the abdomen, as well as vitamin K administration.

question: Identify one nursing problem ( actual problem not "at risk") and formulate one appropriate NANDA nursing diagnosis. Provide rationale to explain why this is the a priority problem

Answer 1

Acute abdominal pain related to disease process as evidenced by pain scale reading

Rationale

* Assess the general condition of Patient

* Assess the vital sign of Patient

* Provide comfortable position

* Provide keep calm environment

* Assess the laboratory investigation

* Monitor the Patient every 2 hourly

* Adminstration of prescribed analgesics

Abdominal pain as I explained the priority problems because Patient admitted in the ED due to abdominal pain ,so abdominal pain have high priority and pain scale reading is increasing ..when a Patient admit with a pain ,as a nurse the important management is to reduce the pain by different nursing rationale and provide pain as a high priority nursing problem