The nurse reviews the patient’s data available in the electronic health record and identifies the following findings that need immediate follow-up

QUESTION

Question 2 Gastrointestinal — Patient 2 Patient Data History and Physical Nurses’ Notes Day ofvisit Intake Current height: 5 feet, 4 inches Current weight: 120 pounds (54 kg) Body mass index: 20.6 kg/m2 Temperature: 98.4° F (369° C) Blood pressure: 118/70 mm Hg Heart rate: 88 beats/minute Oxygen saturation: 99% on room air l6 The nurse reviews the client data available in the electronic health record. Click to highlight the findings that the nurse needs to follow up on immediately. 1210: A 21-year-old female client presents to the emergency department (ED) reporting numerous episodes of bloody diarrhea and lower abdominal cramping. Rates cramping at 4 on a pain scale of 0 to 10. Problems began about 2 months ago, but she declined seeking care earlier because she was “afraid [she] had cancer.” States her roommate finally convinced her to come to the ED when the abdominal pain increased today. She reports having approximately six to seven episodes of bloody diarrhea daily. Denies any family history of bowel problems. Reports drinking one to two alcoholic beverages on weekends when partying with friends and smoking an occasional cigarette but denies being a regular smoker. Estimates having smoked fewer than five cigarettes in her lifetime. Denies use of recreational drugs. In addition to these episodes, fear of cancer, and abdominal pain, she reports she has experienced increasing fatigue and malaise.

ANSWER

The nurse reviews the patient’s data available in the electronic health record and identifies the following findings that need immediate follow-up:

Numerous Episodes of Bloody Diarrhea: The patient reports experiencing numerous episodes of bloody diarrhea. This symptom may indicate a serious underlying gastrointestinal condition that requires further assessment and intervention.

Lower Abdominal Cramping: The patient rates her abdominal cramping at 4 on a pain scale of 0 to 10. Abdominal cramping can be indicative of various gastrointestinal issues and needs to be addressed promptly to determine the cause and alleviate discomfort.

Increased Abdominal Pain Today: The patient’s abdominal pain has increased on the day of the visit. This acute exacerbation of symptoms warrants immediate evaluation to rule out any acute complications or worsening of the underlying condition.

Increasing Fatigue and Malaise: The patient reports experiencing increasing fatigue and malaise. These symptoms could be signs of systemic involvement and potential complications, which require further investigation.

Considering these findings, it is crucial for the nurse to promptly assess the patient’s condition, conduct a comprehensive physical examination, and collaborate with the healthcare team to determine the appropriate diagnostic tests and interventions to manage the patient’s gastrointestinal symptoms and address potential underlying health issues.