Walden University - NURS 6550N Week 9 IHuman Interview Questions (Solution) 2021 UPDATEDMr. Jason Towns is a 32 y.o male with PMH HTN and back pain
... [Show More] related to occupation, presents
with acute onset of left flank pain radiating to left groin starting about 2 hours ago. The pain is
described as a sharp, shooting, stabbing pain rating it a 7/10. He states he has never had pain like
this before. Initially related it a pulled muscle when he first felt it the night before until about 2
hours ago. The pain is intermittent and comes in cycles causing pain to be bearable to
unbearable, and then it goes away. When pain intensifies, he is unable to take a deep breath due
to pain, stating he is only able to take shallow breaths. Endorses nausea and vomiting, especially
with the unbearable episodes of pain. The patient describes the vomitus as undigested food. Mr.
Towns endorses taking Tylenol for pain, as well as using ice and heat to the area without relief of
symptoms. Denies chest pain, SOB, fevers, chills, diarrhea. Urinary symptoms include the
inability to initiate urine stream, and urine is darker in color than normal per patient. No dysuria,
hematuria, pyuria, urgency, or frequency. The patient is noted to be mildly diaphoretic, appears
restless and unable to sit still. Denies tobacco or illicit drug use. He does drink 1-2 drinks on the
weekend. He works in construction but denies any known injury. He takes HCTZ for blood
pressure which is controlled. FMH positive for cardiovascular disease, HTN, DM, and arthritis.
Mr. Towns is afebrile, tachycardiac, and hypertensive at time of assessment.
Primary Diagnosis: Nephrolithiasis/kidney calculi
Status/Condition: Stable
Code Status: Full
Allergies: NKA
Admit to Unit: Medical
Activity Level: as tolerated
Diet: NPO
IVF: 18g IVL x 2 1L bolus then NS at 125 ml/hr.
Critical Drips: N/a
Respiratory: N/A
Medications:
Hold HCTZ (can cause hyperuricemia)
Amlodipine 5 mg PO now and then QD
Tamsulosin 0.4 mg PO now and then QD
Metoclopramide 10 mg IV q6h PRN for N/V
Toradol 30 mg IV now and then 15 mg IV Q6H pain
Acetaminophen 1000 mg IV Q6H PRN fever greater than 101.5, pain less than 5. maximum
4000 mg/day
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shared via CourseHero.comMorphine 4 mg IV Q4H PRN for breakthrough pain, monitor BP. Do not give if SBP<90 and notify the provider
Nursing Orders: VS Q4H. Notify provider SBP<90or >150, HR <60 or >100, O2 sat<90% Notify provider of s/s of hypovolemia, respiratory or neurological changes Daily weight Monitor strict I/O Strain all urine for stone
Follow Up Lab tests: U/A, Spot urine for calcium, uric acid, citrate, oxalate, sodium, potassium, and creatinine, CBC and CMP daily.
Diagnostic testing: CT abd and pelvis without contrast
Consults: Urologist-new onset nephrolithiasis
Patient Education and Health Promotion Pathophysiology of nephrolithiasis risk factors of the disease Symptoms of nephrolithiasis Prevention of progression of nephrolithiasis
Discharge planning and required follow-up care Discharge patient home on PO medications when stable F/U with PCP within 24-48 hours. F/U with surgeon per his order Take medications as ordered. Do not stop or skip the medications even if you feel better without consulting the PCP. Call your healthcare provider right away if you have any of the following: Tiredness that persists for 2 to 3 days, [Show Less]