Read the following case study and develop a plan of care for this patient, which includes at least 2 nursing diagnoses and interventions with rational.
The paper should be 3 – 5 pages long and address the questions presented with the case study.
Esperanza Vasquez has been admitted to a medical-surgical unit with a chief complaint of “pain of unknown origin.” She is 39 years old, married, has two teenage children, and works with her husband in their landscaping business. As you prepare for the admission assessment, her mother, Mrs. Reyes, who brought Esperanza into the hospital, tells you that they fear that Esperanza has “empacho.” Esperanza agrees.
What is “empacho” and how would you handle the situation?
During the assessment, you ask Esperanza to describe the pain in her own words. She begins to sob and says that she finds it hard to describe the pain. She says that she has given birth twice and that this pain is worse, but it only happens after she eats dinner and goes away after a few hours. She is not in severe pain now but complains of a constant slight ache in her stomach.
What questions should you ask as part of your pain assessment?
What tools are available to assist with pain assessment?
Which would you choose and why?
In answer to your assessment questions, Esperanza points to her right upper quadrant and states that the pain starts after she eats a heavy dinner but not every evening. The pain episodes began a month ago. She says the pain begins suddenly, lasts for 2 to 4 hours, and is a sharp “crampy ache.” It does not radiate to other places but stays over her right upper quadrant. She says that nothing she has tried makes the pain better. She has tried over-the-counter antacids, laxatives, and herbal remedies. She usually goes to bed with a heating pad until it subsides. She is unable to help her kids during these episodes because she must lie very still, and this upsets her. You ask her to rate her pain on a numeric scale with 0 being no pain and 10 being the worst pain. She says that right now her pain is at a 2 but that during these episodes it is “above a 10.” She also feels nauseated, sweaty, and weak during these painful episodes.
Is she feeling acute pain or chronic pain? Explain.
As you continue your assessment, you focus on the abdomen. From the health history, you learn that Esperanza prepares her family’s largest meal in the evening and that the pain episodes occur about an hour after eating and last for 2 to 4 hours. She says she is nauseated with these episodes and has occasionally vomited. She has not noticed any weight loss. She has had two episodes of diarrhea. On inspection, you see that her abdomen is slightly obese and symmetric but not rounded. Her skin is smooth, with a few striae on the lower abdomen. She has no scars or lesions. Her bowel sounds are present in all quadrants and normal. No bruises are present. Percussion reveals no abnormalities. Her abdomen is soft on light palpation, and she guards when you touch the right upper quadrant area. You decide to omit deep palpation at this time, but you do check for rebound tenderness, which is not present, and the iliopsoas muscle test, which is negative. However, Murphy’s sign (inspiratory arrest) is present.
What do these findings suggest?
Is Esperanza experiencing visceral pain, deep somatic pain or cutaneous pain? Provide an explanation.
Please be sure to present your responses in APA format.
Please review the rubric to ensure that your assignment meets criteria.
NU510 Critical Thinking Assignment 1 (1)
NU510 Critical Thinking Assignment 1 (1)
Criteria Ratings Pts
This criterion is linked to a Learning OutcomePlan of Care
Elements of the plan are adeptly documented.
Elements of the plan are appropriately documented.
Elements of the plan are satisfactorily documents but either do not demonstrate assessment of current practices or are incongruent across aspects.
Elements of the plan are either not satisfactorily documented, or do not demonstrate assessment of current practices or are incongruent across aspects.
Elements of the plan are either not satisfactorily documented, do not demonstrate assessment of current practices and are incongruent across aspects.
Elements of a plan are not evidenced in the assignment.
This criterion is linked to a Learning OutcomeInterventions and Rationale
Clearly and accurately describes multiple interventions supported by a very strong rationale; clearly supports all details of the presented case.
Accurately describes some interventions supported by a strong rationale; clearly supports most details of the presented case.
Accurately describes interventions supported by a rationale; supports few details of the presented case.
Somewhat inaccurately describes interventions or not supported by a rationale; or does not support most details of the presented case.
Inaccurately describes interventions; not supported by a rationale; does not support the details of the presented case.
Did not attempt the assignment.
This criterion is linked to a Learning OutcomeAPA
The required APA elements are all included with correct formatting, including in-text citations and references.
The required APA elements are all included with minor formatting errors, including in-text citations and references.
The required APA elements are all included with multiple formatting errors, including in-text citations and references.
The required APA elements are not all included and/or there are major formatting errors, including in-text citations and references.
Several APA elements are missing. The errors in formatting demonstrate a limited understanding of APA guidelines, in-text-citations, and references.
There is little to no evidence of APA formatting and/or there are no in-text citations and/or references.
Total Points: 45.0