Comprehensive Nursing Case Study: Mr. Smith's Abdominal Pain and Care

This nursing case study focuses on Mr. Smith, admitted to the hospital with severe upper right quadrant abdominal pain. The paper begins with a comprehensive nursing assessment, including CNS, CVS, RESP, ABDO, and RENAL evaluations, along with relevant blood tests. It then highlights ...Read More

Running head: NURSING
Nursing
Name of the Student
Name of University
Author’s note

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Introduction
The case study below highlights the story of a man who is admitted to hospital with
severe abdominal pain in the upper right quadrant. The paper will initiate with a focus on the
comprehensive nursing assessment followed by highlighting three primary priorities of care and
proper discharge planning under social justice framework for health.
CNS/ CVS/ RESP/ ABDO/ RENAL/ OTHER
1. CNS Assessment
According to the case study, the Glasgow coma scale (GCS) of Smith is 15. This is the
maximum score. This signifies that all the sensory organs (eyes, verbal and the motors) are in
full conscious with no acute chances of brain injury. Since Mr Smith's score is 15, this signifies
that opening of eyes are normal with proper blinking at the base line (Score 4) (GCS 2019). The
moving of the limbs is also occurring as per the commands (Score 6). The body temperature of
Mr Smith is 36.5. T and this is the normal body temperature.
2. CVS Assessment
Pulse rate (PR) of Smith is 102 (normal 70 to 100) and is beating at regular interval,
respiratory rate (RR) is 28 beats per minute (normal range: 12 to 20) and blood pressure is
100/60 mmHg (Normal range: 120/80). Thus blood pressure is below normal. Though the case
study failed to highlight any indication for sweating, but taking into the low pressure into
consideration, it can be stated if the blood pressure drops too low, the body's vital organs fail to
receive enough oxygen and nutrients. Under this stage, the body pass on to shock leading to
generation of excessive sweat, rapid breathing, high pulse and blue skin tone (cyanosis)(Carrick

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et al. 2016). Mr Smith’s RR and PP was high and there is no change in skin colour as his SpO2
was not alarmingly low.
3. RESP Assessment
a) Inspection: The respiratory rate is high and with high respiratory rate there occurs
increase rise and fall of chest. The SpO2 is 94% and thus there would be no chances of
cyanosis and he has previous reported cases of pulmonary embolus.
b) Palpation: Measurement of pain can be done accurately by the use of PQRST framework.
 P (provocation) indicates that pain has arisen due to pain in abdomen that is radiating
to back. The pain mainly started after having dinner at 1800 (chops and vegetables).
No reporting of rib fracture was stated at the time of admission however,
 Q (Quality) of the pain includes gnawing in nature indicating extremely distressing
pain.
 Region (R) of pain include right upper quadrant of the abdomen that is travelling to
the back.
 Severity (S) of pain is high as the score is 9/10. The pain was consistent with no
slowing down.
 Time (T) of pain sensation was post dinner (1800 hours) and Smith was admitted at
2000 hours.
c) Percussion: the sound of lungs is not prolong
d) Ausculation: No difference in sound

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ABDO Assessment
a. Inspection: There is no visible scar over the abdomen. There are indication of abdominal
distension or signs of nausea and vomiting
b. Auscultation: The pain is in the right upper quadrant of the abdomen and might be
indication of gall stones or other complications in the hepatobiliary system (Cook et al.
2019). No indications were given for hyper or hypo bowel sounds
c. Percussion: There are indication of gas sounds were present (tympanic sound). In case of
abdominal distension there tympanic sounds (Cook et al. 2019)
d. Palpation: The pain score is 9 out of 10
4. RENAL Assessment
There no past medical history of renal complications.
5. Others
The main blood text that must be undertaken in this case is complete blood count (CBC). The
complete blood count test will help in understanding any possible signs of internal infections (it
will be indicated by high levels of neutrophils and macrophages) or haemorrhage in the right
upper quadrant of the stomach (due to rib injury, if any). The signs of haemorrhage will be
indicated by increased level of erythrocyte sedimentation rate. Additional blood test that must be
undertaken include amylase and lipase test that must be undertaken include amylase and lipase
test. Amylase and lipase are the principal digestive enzymes. Amylase helps the body to break-
down starches and lipase helps to digest fats. The digestive organs, pancreas secretes these two
digestive juices. Malfunction in the pancreas leads to decrease in the secretion of these two
digestive juices. Thus amylase and lipase test will leads to poor concentration of both of the

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enzymes in the blood serum. Smit has developed pain after consuming vegetables and chops.
Vegetables have high concentration of starch and reduced secretion of amylase is leading to
indigestion causing pain in upper quardrant. Apart from blood test additional test that must be
conducted include:
 Stool test: helps to understand the present of bacteria, viral or parasitic infection in the
digestive tract or the presence of occult blood (hidden blood). No presence of micro-
organism found. Smith has no travel histories and thus chances of giardia is low.
 Abdominal x-ray: Will help to get a detailed picture of the structure of the stomach,
pancreas, lives, intestines and spleen and thus helping to get an idea of unexplained pain.
 BGL: Will help in estimating the amount of glucose present in blood serum and high
level of BGL will indicate the presence of diabetes
 Ultrasound: the non-ionising image of stomach will help to indicate any chances of the
ulcer formation in stomach
 ERCP: Will help in the assessment of the pancreatic and bile ducts condition.
(Berman, Snyder and Frandsen 2016)
Primary priorities
Pain management
The pain score of Smith is 9/10 thus first nursing priority will be reduction in pain. This
can be done with the help of medication management. The main medications that can be used for
this pain management include buscopan, fentanyl IV and ondansetron IV. Fentanyl is a strong
synthetic opioid it has analgesic effect. It is a mu-selective opioid agonist that activates other
opioid system receptors leading to generation of analgesia resulting in pain management. It also

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activates dopamine (neurotransmitter) that activates the relaxation effect of the smooth muscles
and helping to manage pain(Katzung2017).Buscopan helps to reduce the abdominal cramping
and thus managing pain. It is an antispasmodic drug. The drug is given orally and it does not
cross the blood vein barrier and thus is well-tolerated. It is anticholinergic in nature that blocks
muscarinic receptors in the gastro-intestinal tract and thus helps to decrease abdominal
cramping(Katzung2017).Ondansetron will help to reduce the tendency of nausea and vomiting
arising out of excessive abdominal pain (Katzung2017).
The administration of the drugs must be undertaken by registered nurse (RN) by
following six rights of drug administration: patient, route, drug, dose, time, documentation. The
dosage and the time of the administration of the drug will be determined by the doctor and it is
the duty of the RN to follow doctors’ advice. After administration of the drug proper
documentation is important and this will help the “change of shift nurse” to track the patients’
treatment progress and it will help the doctor to adjust the dosage based on disease prognosis. In
general ondansetron IV is injected undiluted, 4mg in not less than 30 seconds or preferably over
2 to 5 minutes(Galbraith et al. 2015).Fentanyl 50 must be administered IV in the form of bolus
and the rate of infusion must be titrated based on patient's response. Mainly 1
micro-gram/kg/minute is the rate(Galbraith et al. 2015). The IV site will be veins in the wrist.
The channel must be made upon under aseptic condition. Smith has no allergy towards any drug
and has no list of medication. The success of the therapy will be evaluated based on decrease in
the level of pain as measured by self-reported pain score.
Fluid resuscitation
Fluid resuscitation will be done with the help of intravenous therapy (IVT). Intravenous
therapy will be done with the help of Hartmann’s solution or normal saline. Finfer, Myburgh and

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Bellomo(2018) stated that during hypotension, aggressive fluid volume resuscitation must be
done with the help of normal saline or Hartmanm’s solution. This helps to restore the normal
blood pressure. Smith is suffering from low blood pressure that can give rise of hemorrhagic
shock and thus IVT is a clinical priority. Mainly wide-bore intravenous access helps in injecting
Hartman's solution or normal saline. Hartmann’s solution is crystalloids in nature containing
sodium chloride and glucose. The entry of sodium chloride in the cell helps to maintain the
extracellular balance of sodium outside the cell. Mainly extra-cellular concentration of sodium
outside the cell is higher than cell’s cytoplasm(Voldby and Brandstrup2016). External supply of
NaCl helps to restore the Na balance and thus facilitating the potassium (K) balance inside the
cell and this will be followed by normalization of body temperature. IV fluid administration
requires constant monitoring for documenting the clinical response and adverse effects in order
to ensure the safety and efficacy. In input and output of the urine must be monitored strictly in
order to adjust the IV administration (Voldby and Brandstrup2016). The input of the fluid must
be monitored based on the oral fluid intake (water or juice) and intake of saline. The output of
the fluid will be monitored based on urine excretion with the help of indwelling catheter. Proper
ratio must be maintained between in-put and out-put of fluid for successful outcome of IVT. The
success of the fluid therapy will be indicated by the improvement in the blood pressure(Finfer,
Myburgh and Bellomo2018).
Resting gut
Resting gut is an approach that helps the gut to heal via eradicating any form of
interferences that is creating a barrier towards comprehensive gut healing. Resting gut also helps
in improving pancreatitis by giving bowel rest. Here feeding through the nasogastric tube help in
restoring the fast nutritional balance while giving rest to bowel and thus helping to cure

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pancreatitis. It is the duty of the nursing professional to aim skillfully the naso-gastric tube
(NGT). In case of Mr Smith, it would be the insertion of the fine bore NGT because Smith will
require short term enteral feeding. Removal and the replacement of the tube must be considered
after 4-week intervals in order to retain the optimum patency of the NGT(Chavda et al. 2017).
For long term, enteral feeding.gastrostomy or jejunostomy tube. NGT must only be inserted after
the conduction of the chest X-ray in order to determine the exact location of the nasal pipe up to
oesopharynx. After insertion of the NGT, another X-ray must be conducted in order to detect the
pattern of insertion. The tube must be inserted after the RN conducts the basic nursing practice,
washing of hands with alcoholhand rub and this will help to reduces the chances of developing
nosocomial infection arising out the direct touch or hand contact. Verbal consent from patient or
his family members must be taken before proceeding with the insertion of NSG. During
insertion, the tube must be lubricated and the NGT will past through selected nostrils towards
oropharynx that encourage the people to swallow directly. Careful insertion must be done to
prevent tube knotting (Chavda et al. 2017).Caple and Pravikoff (2016) stated that insertion of
NGT is a blind procedure. the tube must be passed through nose along the nasal floor through the
pharynx and down the esophagus. The tube will be inserted until the proximal tip of the tube
rests in the stomach of the patient.
Discharge planning
The discharge planning must be done with the use of the social justice framework that
promotes effective promotion of health. Four principles of social justice framework include
equity, access, participation and rights (Liebig and Sauer 2016). The equity signifies that the
access to healthcare must be done by writing referral to community-based doctors or a gastro-
entrologist. The presence of a gastroenterologist will help in proper health management of Smith

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post discharge and community-health nurses will promote healthcare awareness. Smith has eye-
sight problems and thus must be referred to ophthalmologist. Participation signifies that it is the
right of every patient to take part in the decision making process. This helps in generation of
patient centered care plan and at the same time increases patient participation in the care. Both
Smith, his wife and his wards will be included in the process of therapy planning. This will be
done by triage nurses (upon hospital release). Communicating and explaining about disease
progression help to increase patient engagement. Access to healthcare will be increased by
making referral to local healthcare services in order to promote early identification of stomach
pain vulnerability. Rights of the patients include autonomy, beneficence and non-malificence.
Patient’s’ consent will be taken before finalizing discharge planning(Liebig and Sauer 2016).
Conclusion
Thus from the above discussion, it can be concluded that the three main priorities of care
based on the comprehensive nursing assessment are pain management, IVT and resting gut. The
management of pain will be done with the help of IV fluid as prescribed by doctors like
analgesic. The IVT will be done through Hartmann solution and this will help to restore low
blood pressure. The resting gut will be achieved through NGT insertion.

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References
ACT Government Health. (2019). Canberra Hospital and Health Services Clinical Procedure:
Nasogastric Tube (NGT) Management– Adults only. Canberra Hospital and Health Services.
Berman, A., Snyder, S. and Frandsen, G., 2016. Kozier&Erb's Fundamentals of Nursing:
Concepts, process and practice. Boston, MA: Pearson.
Caple, C. and Pravikoff, D., 2016. Nasogastric Tube: Inserting and Verifying Placement in the
Adult Patient.
Carrick, M.M., Leonard, J., Slone, D.S., Mains, C.W. and Bar-Or, D., 2016.Hypotensive
resuscitation among trauma patients. BioMed research international, 2016.
Chavda, V., Alhammali, T., Farrant, J., Naidu, L. and El-Rabaa, S., 2017. Nasogastric tube
knotting: a rare and potentially overlooked complication among healthcare professionals. Case
Reports, 2017, pp.bcr-2017.
Cook, N., Shepherd, A., Boore, J. and Dunleavy, S., 2019. Essentials of Pathophysiology for
Nursing Practice. SAGE Publications Limited.
Finfer, S., Myburgh, J. and Bellomo, R., 2018.Intravenous fluid therapy in critically ill
adults. Nature Reviews Nephrology, 14(9), p.541.
Galbraith, A., Bullock, S., Manias, E., Hunt, B. and Richards, A., 2015. Fundamentals of
Pharmacology: An applied approach for nursing and health. Routledge.
GCS. 2019. The Glasgow Structured Approach To Assessment Of The Glasgow Coma Scale.
Access date: 1st Sept 2019. Retrieved from: https://www.glasgowcomascale.org/

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Katzung, B.G., 2017. Basic and clinical pharmacology.McGraw-Hill Education.
Liebig, S. and Sauer, C., 2016.Sociology of justice.In Handbook of social justice theory and
research (pp. 37-59).Springer, New York, NY.
Voldby, A.W. and Brandstrup, B., 2016. Fluid therapy in the perioperative setting—a clinical
review. Journal of Intensive Care, 4(1), p.27.