Liza Madrid a 35-year-old was admitted to the female medical ward due to persistent vomiting (4x) and severe abdominal pain since 4:00 in the morning. She was endorsed to the floor nurse by the ER...

Liza Madrid a 35-year-old was admitted to the female medical ward due to persistent vomiting (4x) and severe abdominal pain since 4:00 in the morning. She was endorsed to the floor nurse by the ER nurse. She is on IV fluid of D5NSS 1L to run at 125 ml/hour, she is on NPO. Upon assessment of the staff nurse her Vital signs as follows BP 130/80, PR 87 bpm, RR 25 cpm, T 37.5 °C. she is weak and pale in appearance and with facial grimace and her hands are on her abdomen, and feeling nauseated. The doctor ordered for laboratory examination; CBC, blood chemistry, FBS, BUN, urinalysis, and stool examination. Plasil 10 mg IM was given in the ER at 5:00 AM and every 8 hours PRN for abdominal pain, Buscopan 20 mg IM was also administered at 5:10 AM and every 6 hours PRN for abdominal pain. VS to monitor every 4 hours and to monitor persistent of vomiting and abdominal pain. She is scheduled for abdominal ultrasound, the blood investigation results came, her CBC are with in normal range, as well as the FBS and BUN, her serum potassium level is at very low normal range, the doctor changed her IV fluid to Plain NSS 1L + 60mEq KCl at 21 drops per minute, the following morning she undergone abdominal ultrasound and found out to have acute gastric ulcer. Omeprazole 40 mg IV was initiated and Cephaloxin 500mg IV twice a day. After three days her condition improved and was discharged with home medication instruction and OPD appointment, she was started on soft diet. II. 1. Make an NCP for Liza     2. One short term goal and one long term goal     3. Make a rationale for every nursing intervention.
Jun 10, 2022
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