*Acute abdomen and complications*
NURSING ASSESSMENT Correct Answer: Should take a *history* - Type of pain, nature and onset, location, quality.
Change in bowel habits.
Ask about history of trauma, gynecological history, anorexia, malaise.
Assess for tachycardia, hypertension, fever, nausea/v...
PBDS Cards questions with complete solutions
*Acute abdomen and complications*
NURSING ASSESSMENT Correct Answer: Should take a *history* - Type of pain, nature and
onset, location, quality.
Change in bowel habits.
Ask about history of trauma, gynecological history, anorexia, malaise.
Assess for tachycardia, hypertension, fever, nausea/vomiting.
*Inspect*- look, listen, feel
*Acute abdomen and complications*
PRIORITY INTERVENTIONS Correct Answer: Administer pain medications
Keep the patient quiet and not under stress
Assess for trauma - bleeding, blunt, crushing, piercing
Treat the trauma if this is indicated
*Acute abdomen and complications*
DATA TO REPORT Correct Answer: Describe the pain - level x/10, location, quality, duration,
onset
Change in bowel habits, temperature should be conveyed
Respiratory status, pulse, and blood pressure can indicate active bleeding and/or shock
Trauma findings, if any
*Acute abdomen and complications*
ANTICIPATED ORDERS Correct Answer: Pain medications - pain is a primary concern here
NPO - do not introduce any new food or stimulus into the altered abdomen
Nasogastric suction
Meds: antiemetics, narcotics, analgesics, IV fluids
Labs drawn
*Acute abdomen and complications*
MISCELLANEOUS INFORMATION Correct Answer: Check CBC for H/H
Urinalysis (UTI - pyelonephritis/-osis)
Check for pyuria (pus), hematuria, glucosuria, ketones
*Serum HCG (pregnancy)*
Electrolytes and glucose
>40 years
EKG, KUB
Chest x-ray
Abdominal CT
Stool guaiac test
*Congestive heart failure and complications*
NURSE ASSESSMENT Correct Answer: Auscultate lung fields for edema
Measure blood pressure
, Measure pulse
Check patient history
Recent weight gain - circulatory and peripheral edema
*Congestive heart failure and complications*
PRIORITY NURSING INTERVENTIONS Correct Answer: *Raise the head of the bed first to
facilitate breathing and gas exchange*
*Then administer oxygen*
Monitor pulse oximetry
Antiembolism stockings
*Congestive heart failure and complications*
DATA TO REPORT Correct Answer: *Blood pressure*
*Respiratory status*
*Pulse*
Report patient recent weight gain
Report edema
Report intake and output
Report meds the patient is taking
*Congestive heart failure and complications*
ANTICIPATED ORDERS Correct Answer: Chest x-ray
Cardiac monitor
Potassium, electrolytes
*BNP draw* - measures heart function. Elevated in distress and in heart failure.
BUN and creatinine
Arterial blood gases
*Congestive heart failure and complications*
MISCELLANEOUS INFORMATION - LABS Correct Answer: Respiratory alkalosis
Increased creatinine if CHF is severe
Changes in wedge pressure - increased
*Diabetic ketoacidosis and complications*
NURSE ASSESSMENT Correct Answer: *Dehydration*, thirst
*Hypotension* or hypertension
*Polyuria, glycosuria*
Change in LOC
*Monitoring heart function, changes in function*
*Metabolic acidosis*
Hyperglycemia
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