Case Study Abby Nightingale came into the ER with a chief co…
Case Study Abby Nightingale came into the ER with a chief complaint of a headache that “will not ease up”. She describes it as a band around her head with a squeeze like feeling. It seems to last all day per the patient. Stress makes it worse, and Tylenol does reduce the severity. She has been taking Tylenol around the clock. Abby feels that it is just stress or lack of hydration. She reports drinking more water than her normal, about 12 cups a day compared to 8 cups. She rates her pain currently a 6/10, worst 10/10, best 4/10 after medication. She does state feeling more tired and fatigued. Prenatal records show that last weight recorded at a previous office appointment was 130 pounds from 3 days ago. Abby Nightingale • 31 years old • 34 weeks gestation • Gravida 1, para 0• Weight 137 lbs.• Home meds – Prenatal vitamin Vitals 98.7 degrees F RR 20 HR 70 Pain 6/10 BP 150/82 PO2 93% room air Upon arrival to the perinatal unit the nurse performs an assessment on Abby. Listed below are the findings of the physical assessment. • 31 years old • 34 weeks gestation • Gravida 1, para 0• Weight 137 pounds • Head – Alert and oriented x 3 – Periorbital edema – Headache present – Visualizes spots• Cardiovascular – Heart sounds regular – No chest pain – Pedal pulses +1 – Post tibial pulses +1 – Popliteal pulses +2 – +2 pitting edema bilaterally – Skin turgor – 1 second return• Respiratory – Lungs are clear throughout – No SOB – No cough• Urinary – Denies UTI symptoms – Has urinated 1x in 9 hours• Gastrointestinal – Bowel sounds are positive – Abdomen- Soft, non-tender – Intermittent nausea, no vomiting – Last BM yesterday – States of a decreased appetite• Vitals signs – HR 80 – RR 20 – PO2 96% room air – BP 168/86 – Pain 7/10 Intake- 40 oz (1200 ml)Output- 40 ml What findings should the RN report to the doctor rounding on the perinatal unit? Select all that apply.