Problem
Scenario:
You are the nurse working on a gastrointestinal/genitourinary (GI/GU) floor, your charge nurse tells you that you will be receiving an admission from the emergency department, ETA (estimated time of arrival) 45 minutes. She gives you the following information:
Patient identification
H.L. is a female, 20 years old who presented to the ED with abdominal pain NYD (not yet diagnosed). She weighs 45 kgs with a height of 5-foot 1 inch.
Present medical history
H.L. complains of 7/10 diffuse abdominal pain, crampy in nature that comes and goes; occasionally the right lower side is worse than right. Her appetite has been poor for 3 days, stating she feels "too full to eat". She has not passed stool or flatus/gases for 4 days with ongoing progressive nausea and retching. One episode of emesis occurred after she couldn't keep solid food down yesterday. Nothing but liquids for PO (per oral) intake today. She reports having a low-grade fever for 2 days.
She works at Starbucks and recently missed two days of work this week. She states she feels weak and reports her last menarche was 3.5 weeks ago.
Past medical history
H.L is a generally healthy individual. Mild anxiety. Active and walks to work regularly. Recent trip and fall with a severely sprained ankle, tensor wrapped (no splint or cast).
Objective Data
T 37°C, P 117, R 14, BP 120/68, and oxygen (02) saturation is 96%
Abdomen distended, semi-firm. Tender to palpate all four quadrants, worse in right lower quadrant. Bowel sounds hypoactive upper quadrants, and left lower quadrant, absent right lower quadrant.
Medications: birth control, PRN Tylenol #3 for sprain
• Calculate H.L.'s BMI (to one decimal place only)