History of Present Problem: Sean Donald is a 55-year-old male with…History of Present Problem: Sean Donald is a 55-year-old male with…

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Question Answered step-by-step History of Present Problem: Sean Donald is a 55-year-old male with… History of Present Problem: Sean Donald is a 55-year-old male with a history of cirrhosis and ETOH abuse who has not had any medical care the last ten years. He began vomiting large amounts of bright red blood when he woke up this morning. He was found on the floor of the bathroom by Sheila, his girlfriend, when he became lightheaded and fell on the floor and was too weak to get up. Sheila called 911. Paramedics report that there was a large dark red/black stool in the toilet. They were able to get an 18-gauge IV in the right antecubital vein, and Jim received 500 mL of 0.9% NS. His initial BP was 80/40 at the scene, and his most recent BP is 82/44 with a current heart rate of 128, sinus tachycardia. Personal/Social History: Sean recently lost his job as a construction laborer and was divorced six months ago. His ex-wife has full custody of his two children. Sean’s girlfriend states that he has been more depressed lately and has been drinking more heavily since his divorce. He takes ibuprofen daily for chronic back pain. Current VS:P-Q-R-S-T Pain Assessment:T: 98.2 F/36.8 C (oral)Provoking/Palliative: P: 138 (regular)Quality:DeniesR: 28 (regular)Region/Radiation: BP: 74/30 MAP: 45Severity: O2 sat: 95% room airTiming: Current Assessment:GENERALAPPEARANCE:Lethargic, body tense, appears uncomfortable but denies painRESP:Breath sounds clear with equal aeration bilaterally ant/post, non-labored respiratory effortCARDIAC:Pale, extremities cool, no edema, heart sounds regular with no abnormal beats, pulses weak,equal to palpation at radial/pedal/post-tibial landmarks, 1-2 second capillary refillNEURO:Alert & oriented to person, place, time, and situation (x4), whispers responsesGI:Abdomen flat, soft/non-tender, bowel sounds audible per auscultation in all four quadrants, feelsnauseatedGU:No urine output presentSKIN:Skin integrity intact, skin turgor elastic, no tenting presentDiagnostic Results:Basic Metabolic Panel (BMP) NaKGluc.Creat. Current:1344.88.01.9  Complete Blood Count (CBC) WBCHGBPLTs% Neuts Current:8.555 g/L6875  Liver Panel AlbuminTotal BiliAlk. Phos.ALTASTCurrent:2.13.51526875 MISC. LactateMgPT/INR  Current:3.41.38.5  CAN YOU PLEASE HELP FOLLOWING TO WRITE REFLECDTIONDescribe a situation in which you, as a nurse, had to make a correct clinical judgement in order to either advance orthe plan of care or to recognise clinical data in the case study that represented a change in clinical status?What can be drawn from it?What would you have done differently?? How will you put this knowledge to use in the future? Health Science Science Nursing NURS 401 Share QuestionEmailCopy link Comments (0)