Gastrointestinal Assignment Patient Case

Patient Case- you should embellish and add additional details to the patient case as needed to reflect full documentation of a musculoskeletal problem, but please use the following basic information to document about your patient:

Subjective Data: Includes patient history and all other subjective data.

  • Mr. Chevy, a 46-year-old Caucasian male
  • Admitted diagnosis: gastrointestinal (GI) bleed.
  • Medications include omeprazole, Thiamine, Vitamin B, and Folate supplements.
  • Allergies to morphine, ibuprofen, and tetracycline.
  • Substance use- alcohol – (might want to ask him about his alcohol intake)
  • Currently: Mr. Chase reports that five minutes prior to nurse entering the room, he vomited bright red blood into the garbage can. Patient reports, “I threw up four times in the last four hours.” Patient states, “I just felt it coming on fast. I knew I shouldn’t have eaten that food…” ask him some more PQRSTU about his vomiting/abdominal system
  • Pain: 4/10 – ask him some PQRSTU about the pain
  • He also reports feeling nauseous, fatigued, and anxious.
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Objective Data: Includes all Physical Exam (e.g., Vitals, your inspection, auscultation, percussion, and palpation results)

  • Vital Signs: Oral Temp 36.5 C, HR 124 BPM, RR 24, and BP 100/62 mm Hg. SpO2 93%. Weight 55 kg (last weight 65 kg). Height: 5ft 10.08 inches
  • Inspection: Abdomen distended-. Document the rest of inspection as a normal or expected findings.
  • Auscultation: Bowel sounds hyperactive in all four quadrants. Document rest of auscultation exam as normal or expected findings
  • Palpation: Abdomen firm and slightly tender in all quadrants. Other palpation documentation should reflect expected or normal findings

Describe Two Actual or Potential risk factors based on the assessment findings, with description or reason for selection of them

  1. Mr. Chevy is at risk for…………………………………due to…………………………
  2. He is also at risk for………………due to …………………………………………………….