7. The nurse is cuing a post-op client to cough and deep bre…
Questions
7. The nurse is cuing а pоst-оp client tо cough аnd deep breаth. The client states, "I am not sure what happened but it felt like something ripped." Upon further evaluation the client's abdominal wound is noted to be open and evisceration has occurred. Which of the following actions will the nurse perform first?
Tаsk fоr this OSCE: Using the essаy spаce prоvided, please dоcument a complete and thorough physical examination from your OSCE patient encounter Be sure to document any and all specific exam findings that you observed or were provided during the encounter. Below you will find a copy of the information provided during the OSCE: Case Information Patient Name: Maya Presley Age: 39 y/o Gender: Female Chief Complaint: “I think I have a UTI” Vital Signs: Temperature: 37.1°C (98.8°F) Pulse rate: 75 Respiration rate: 16/min Blood pressure: 128/86 mmHg Oxygen saturation: 99% on room air Weight: 63.5 kg (140 lb) Height: 165 cm (65 in) HPI: Maya is a 39 y/o female who presents with a complaint of increased urinary urgency and suprapubic/pelvic abdominal discomfort which began 7 days ago. She expresses concern for having a UTI, after looking up her symptoms online. At present, nothing makes her symptoms better or worse. She denies radiation of suprapubic/pelvic discomfort and rates the discomfort at “3 out of 10”. She reports having had “one or two” UTIs in the past, but notes that this is “somewhat different” and shares that she hasn’t had a UTI in several years. Her last UTI was 3 years ago and was successfully treated with antibiotics. She also notes occasional vaginal spotting and a change in vaginal discharge that started this week and that is not typical for her. Her menstrual periods are reported to be irregular at baseline, often occurring between 25 and 32 days apart. Her LMP was 3 weeks ago. Prior to her visit today, Maya sought care through a telehealth urgent care visit on the second day of her symptoms. She notes she was treated for a suspected UTI and provided a prescription for an antibiotic called “Macrobid”, which she took to completion for 5 days. That treatment course ended yesterday, without improvement in her symptoms. Pt denies fever, dysuria, diarrhea, constipation, nausea, vomiting or flank pain at this time. No vaginal itching. No pelvic pain with movement. No recent or preceding injuries, surgeries, or events to explain the pain. She denies hx of kidney stones in the past. Past Medical History: Illnesses/Injuries: Chronic conditions: ADHD, Gluten intolerance OB-GYN Hx: G0P0; atypical pap smear 3 years ago (ASCUS); HPV (7 years ago); gonorrhea cervicitis (treated successfully 5 years ago) Hospitalizations: None Surgical History: None Immunizations/Health Maintenance: Up to date on all vaccines, including yearly COVID/influenza and HPV vaccine series Medications (Prescription, Over the Counter, Supplements) Over-the-counter daily multivitamin Dextroamphetamine/amphetamine (Adderall) XR 10mg PO once each morning Allergies (e.g. environmental, food, medication and reaction) Sulfa drugs (reaction: anaphylaxis by pt report) Family Medical History: Father: alive, 80 years old, diabetes mellitus type 2 Mother: passed away at 61 years old due to stroke Brother 1: 35 y/o alive, no known medical problems Children: none Social History: Tobacco/Vape: Yes, use vape (nicotine product) multiple times daily for the last 4 years. Alcohol: Has 1-2 glasses each week total, no other alcohol intake reported. Illicit drugs: Denies. Marital/Sexual: Single. Pt reports being sexually active with multiple consensual partners over the last 6 months. She identifies as bisexual. Pt reports that her most recent sexual activity was 12-14 days ago with a new partner. No birth control or condom was used as that person informed the patient that he had a vasectomy. Pt denies sexual abuse. Living situation: Lives in La Mesa Job: Commercial real estate marketing representative Hobbies: DIY projects, volunteering for a soup kitchen Diet: Healthy, protein rich; avoids gluten (by choice) and all fast food Review of Systems: General No fever/chills. No recent unexpected weight changes. No night sweats. Skin Denies rashes, bruising, or unusual skin discoloration. No report of jaundice. Head No headache. No head trauma reported. Eyes No vision changes. No double vision or eye pain. Pt denies conjunctivitis. Ears No hearing loss, tinnitus, otorrhea, or otalgia (ear pain) Nose/Sinuses No nosebleeds, discharge, or rhinorrhea Throat/Mouth/ Neck No neck pain, sore throat, hoarseness, swelling, or neck stiffness. No lymph node swelling. Respiratory No cough, shortness of breath, orthopnea, dyspnea, or hematemesis. Cardiovascular/ PV No chest pain, palpitations, swelling or edema of the extremities. No extremity discoloration or cold extremities reported. Gastrointestinal See HPI. Genitourinary See HPI. Musculoskeletal Denies joint swelling, redness, warmth or myalgias. Psychiatric No anxiety, depression, hallucinations, and homicidal or suicidal ideations Neurologic Denies confusion, syncope, paresthesias, numbness, or muscle weakness. No dizziness. Hematologic / Lymph Denies easy bruising or bleeding. Denies gum bleeding. Endocrine No reported heat or cold intolerance. No changes to hair, skin, or nails reported. Intake/Triage Diagnostic Testing Performed: Urinalysis (collected and processed at patient intake): PATIENT RESULT: REFERENCE: Color: Clear yellow Appearance: Clear Leukocyte esterase: Present Nitrites (mg/dL): Negative Urobilinogen (mg/dL) 0.3 Protein (mg/dL): Trace pH: 6.5 Blood (mg/dL): Negative Specific gravity: 1.021 Ketones (mg/dL): Negative Bilirubin (mg/dL): Negative Glucose (mg/dL): Negative RBC: None WBC: 5 Squamous epi cells: None Bacteria: None Mucus: Present Color clear to yellow Appearance clear Negative Negative 0.2-1 Negative 5.0-9.0 Negative 1.005-1.030 Negative Negative Negative 0-5/HPF 0-3/HPF Negative Negative Negative Urine pregnancy test (b-hCG): Result: Negative ***END OF STUDENT INFORMATION***