Nursing Assessment for Acute Abdomen

Questions and Answers

What nursing assessment should be made for acute abdomen complications?

History of pain (type, nature, onset, location, quality), changes in bowel habits, history of trauma, gynecological history, anorexia, malaise, tachycardia, hypertension, fever, nausea/vomiting; Inspect abdomen (look, listen, feel).

What are the priority nursing interventions for acute abdomen complications?

Give pain meds, keep patient quiet, assess for trauma and treat if indicated.

What information should be reported to the doctor related to acute abdomen complications?

Pain levels, location, quality, duration, onset time, changes in bowel habits, vital signs, nausea/vomiting, last menstrual period, trauma findings if indicated.

What orders should be anticipated to be ordered by the doctor for acute abdomen complications?

Pain meds, NPO status, labs, IV fluids, nasogastric suction, antiemetic, narcotics, analgesics, surgical consultation. Signup and view all the answers

What labs/meds should be anticipated to be ordered by the doctor for acute abdomen complications?

CBC, lipase, serum HCG, BMP/electrolytes and glucose, urinalysis, EKG, KUB, chest X-ray, abdominal CT. Signup and view all the answers

What nursing assessment should be made for CHF complications?

Auscultate lung fields, auscultate heart sounds, vital signs, recent weight gain, activity limits, sleep patterns, edema. Signup and view all the answers

What are the priority nursing interventions for CHF complications?

Give O2, raise head of bed, IV access, cardiac monitor, pulse oximetry, antiembolism stockings. Signup and view all the answers

What information should be reported to the doctor related to CHF complications?

Vital signs (BP, respiratory rate, pulse), recent weight gain, activity limits, sleep pattern, current medications, edema. Signup and view all the answers

What orders should be anticipated to be ordered by the doctor for CHF complications?

O2, ECG, chest X-ray, ABG's, cardiac monitor, diuretics, potassium, labs (electrolytes, BUN & creatinine, BNP, cardiac enzymes, ECHO). Signup and view all the answers

What labs/meds should be anticipated to be ordered by the doctor for CHF complications?

Labs (respiratory alkalosis, increased creatinine if severe, changes in pulmonary artery wedge pressure); Meds (diuretics, digoxin, ACE inhibitors, beta-blockers, vasodilators). Signup and view all the answers

What are the signs of digoxin toxicity?

Severe ventricular arrhythmias, progressive bradycardia, heart block not responsive to atropine, potassium levels 5.5+ mEq/L, neurologic symptoms (visual disturbances, disorientation, confusion). Signup and view all the answers

What are normal digoxin medication lab values?

0.5-2. Signup and view all the answers

What nursing assessment should be made for DKA complications?

Evaluate dehydration, blood pressure, metabolic acidosis, tachypnea, nausea/vomiting, abdominal pain, decreased LOC, cardiac changes, history. Signup and view all the answers

What are the priority nursing interventions for DKA complications?

Monitor I & O's, replace fluids as ordered with normal saline, monitor blood glucose, cardiac monitor, NPO status, provide reassurance, bed rest. Signup and view all the answers

What information should be reported to the doctor related to DKA complications?

Blood sugar levels, LOC, cardiac changes, pain level and location, vitals, nausea/vomiting. Signup and view all the answers

What orders should be anticipated to be ordered by the doctor for DKA complications?

Labs (serum glucose, electrolytes, BUN, urinalysis, CBC, ketones, serum osmolarity, ABG's), CT of the head if mental status altered, intubation if ordered, IV normal saline. Signup and view all the answers

What labs/meds should be anticipated to be ordered by the doctor for DKA complications?

Labs (serum/urine ketosis, glycosuria, hyponatremia, increased BUN, metabolic acidosis, increased serum osmolality); Meds (insulin drip, potassium, fluid replacement via IV normal saline). Signup and view all the answers

What nursing assessment should be made for AMI complications?

Assessment details are missing. Signup and view all the answers

Study Notes

Acute Abdomen Complications

Assess history by gathering details on type, nature, onset, location, and quality of pain, as well as any changes in bowel habits, trauma history, gynecological history, and presence of symptoms like anorexia, malaise, tachycardia, hypertension, fever, and nausea/vomiting.
Perform a thorough abdominal inspection: look for signs, listen for bowel sounds, and palpate the abdomen for tenderness.
Priority interventions include administering pain medications, keeping the patient calm, and assessing trauma, with treatment provided as necessary.
Report significant findings to the doctor, such as pain characteristics, vital signs, recent bowel habit changes, nausea/vomiting, last menstrual period, and trauma evidence.
Anticipated orders from the doctor may include pain medications, NPO status, laboratory tests, IV fluids, nasogastric suction, antiemetics, narcotics, analgesics, and potentially consulting a surgeon.
Essential labs to expect include CBC for infection signs, lipase for pancreatitis, serum HCG for pregnancy, BMP for electrolytes, and urinalysis to check for pyuria or hematuria.

Congestive Heart Failure (CHF) Complications

Key assessments involve auscultating lung fields, heart sounds, and monitoring vital signs, alongside gathering history of weight changes, activity limitations, sleep habits, and edema.
Provide priority nursing interventions like administering oxygen, elevating the head of the bed, establishing IV access, and continuous monitoring with cardiac monitoring and pulse oximetry.
Report pertinent information to the doctor, including vital signs (BP, respiratory rate, pulse), weight changes, activity limits, sleep patterns, medications, and edema details.
Anticipated medical orders may involve oxygen therapy, ECG, chest X-ray, ABGs, cardiac monitoring, diuretics, potassium supplements, and relevant lab tests.
Labs to monitor include electrolyte levels, BUN & creatinine, BNP for heart failure status, and cardiac enzymes, plus echocardiograms for heart function assessment.
Important medications include diuretics for fluid management, digoxin for contractility improvement, ACE inhibitors, beta-blockers, and vasodilators to reduce cardiac workload.

Diabetic Ketoacidosis (DKA) Complications

Nursing assessment focuses on signs of dehydration, blood pressure changes, metabolic acidosis symptoms, tachypnea or Kussmaul breathing, nausea/vomiting, abdominal tenderness, decreased level of consciousness, and cardiac abnormalities.
Priority interventions include closely monitoring input and output, replacing fluids as necessary with normal saline, monitoring blood glucose levels, cardiac monitoring, placing the patient on NPO status, and providing reassurance.
Report to the doctor critical information such as blood glucose levels, level of consciousness, cardiac changes, pain details, vital signs, and gastrointestinal symptoms.
Anticipated doctor orders likely include labs: serum glucose, electrolytes, BUN, urinalysis, CBC, and ketones, along with a CT scan of the head if mental status is altered and possible intubation.
Key lab findings may indicate serum/urine ketosis, glycosuria, hyponatremia, elevated BUN, metabolic acidosis, increased serum osmolality, and significant anion gap.
Medications to anticipate involve insulin drips for glucose control, potassium for electrolyte balance, and IV normal saline for hydration.

Acute Myocardial Infarction (AMI) Complications

Further assessment criteria for AMI include gathering a detailed history which encompasses current symptoms and risk factors.

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Description

This quiz focuses on the nursing assessment and priority interventions needed for patients with acute abdomen complications. It's designed to enhance your understanding of crucial assessment techniques, history taking, and identifying symptoms that warrant immediate care.