COMPREHENSIVE HEALTH HISTORY

COMPREHENSIVE HEALTH HISTORY
Biographic Data
Client's name : Mr W. Dlamini
Age : 42 years
Address : Luyengo
Marital Status: Married
Nationality : Swazi
Religion : Zionist
Educational level : Primary School
Chief Complaint: Abdominal pain
History of Present Health Concern
C - severe abdominal pain, sometimes colicky abdominal pain
O - started x 1/12 ago
L - abdomen (Right lower quadrant)
D - one month
S - severe, rating about 8/10 according to pain scale
P - pain severe after eating, over-the-counter analgesics have helped to relieve pain but it always comes back.
A - pain is often accompanied by headache, fever and vomiting which makes the client not able to do some of the activities of daily living.
Past Health History: two weeks ago patient was treated for abdominal pain at Luyengo Clinic with little effect. Client has no BCG scar on the left forearm. Late February this year, the patient was hospitalised for a few days following right arm fracture. The client has no known allergies and he knows his HTC status.
Family Health History: Patient states that there is no family history of appendicitis but his grandmother had peritonitis and diabetes mellitus. His older brother, Mandla have gastric ulcers.
Lifestyle and Health Practices: client is a non-smoker but drinks alcohol (sometimes excessively). Patient stated that he usually eat low fibre diet at work. He sometimes forgets washing hands after using the toilet and before handling or eating food.
PHYSICAL EXAMINATION
General observation: On general observation the client is ill-looking, holding his abdomen and restless. During history taking the patient kept on grimacing.
Inspection: abdomen is asymmetric, bulging on the right lower quadrant (RLQ) without any lesions and or bruising noted. Redness noted on the right lower quadrant of the abdomen. Umbilicus slightly shifted from the midline due to inflammation on the right lower quadrant.
Palpation: the skin is hot on touch (T – 38.2 oC) due to infection on the right lower quadrant. On light palpation tenderness noted on the right lower quadrant. Deep palpation was delayed on the right lower quadrant as the client reported severe pain. No masses noted with light and deep palpation in the other three abdominal quadrants. Liver and spleen were non-palpable.
Percussion: area of dullness percusssed at the right lower quadrant. Tympany percussed over the three other abdominal quadrants. 8cm liver span percussed on the right mid- clavicular line.
Auscultation: Venous hum and friction rub auscaltated over the liver. Diminished bowel sounds and right renal artery bruits auscultated over the right lower quadrant. Bowel sounds low pitched and gurgling at 22/min in the other three abdominal quadrants.

DATA ANALYSIS AND SYNTHESIS
Identification of Abnormal findings and client strengths
Subjective Data
Abdominal pain
Abdominal pain accompanied by vomiting
Often fever and headache
Colicky abdominal pain
History of diabetes in the family
Excessive alcohol intake
Low fibre diet
Constipation
Objective Data
no BCG scar
temperature 38.2 oC
hot on touch
grimaced face
Diminished bowel sounds on the right lower quadrant
Right lower quadrant dull on percussion
Tenderness palpated on right lower quadrant
Abdomen asymmetric, bulging on right lower quadrant
2. Identification of cue clusters
Cue cluster 1
temperature 38.2 oC
hot on touch
Headache
Cue cluster 2
Severe, colicky abdominal pain
Diminished bowel sounds on the right lower quadrant
Right lower quadrant dull on percussion
Tenderness palpated on right lower quadrant
Abdomen asymmetric, bulging on right lower quadrant
Cue cluster 3
Excessive alcohol intake
Low fibre diet
Constipation
Vomiting for the past two days
Client was able to come for medical attention
3. Drawing inferences
Cue cluster 1
Signs and symptoms may indicate severe pain and, or the presence of abdominal infection.
Cue cluster 2
Signs and symptoms suggest inflammation of the appendix. Client probably needs a medical referral.

Cue cluster 3
These signs and symptoms may not only suggest client’s poor nutritional status, but may also suggest fluid volume deficit.
4. Possible Nursing Diagnosis
Cue Cluster 1
General body discomfort secondary to systematic response to abdominal infection as manifested by elevated body temperature
Cue Cluster 2
Severe abdominal pain secondary to abdominal infection as manifested by the patient grimacing.
Activity intolerance related to severe abdominal pain as manifested by client’s inability to perform some self care activities.
Cue Cluster 3
Imbalanced nutrition less than body requirements related to frequent vomiting as manifested by poor skin integrity.
Constipation related to decreased dietary fiber as reported by the client.
Risk for dehydration related to vomiting
5. Defining Characteristics
Cue Cluster 1
General body discomfort
Major - none
Minor – hot
Cue Cluster 2
Severe abdominal pain
Major – subjective communication of pain descriptors
Minor – grimacing
Activity intolerance
Major – none
Minor – verbalization of inability to cope
Cue Cluster 3
Imbalanced nutrition
Major – reports consumption of low fiber diet
Minor – none
Constipation
Major – none
Minor – abdominal discomfort
Dehydration
Major – none
Minor – nausea and vomiting
6. Confirming or ruling diagnoses
Cue Cluster 2
Abdominal pain confirmed because it meets all the defining characteristics.
Activity intolerance ruled out because it does not meet all defining characteristics.
Cue Cluster 3
Risk for dehydration ruled out because it does not meet all defining characteristics.

7. Documenting Conclusions
Nursing diagnoses that are appropriate for this client include:
Severe abdominal pain secondary to abdominal infection as manifested by the patient grimacing.
Collaborative Problems (Risks for Complications)
RC – Peritonitis
RC – Abscess Formation
RC – Bowel Obstruction
Medical Problems / Nursing Actions
To give analgesics to relieve pain and fever. Also give antibiotics to fight against bacterial infection
To give oral rehydration salt, and monitor vital signs and hydration status or nutritional status. If the client does not recover or show improvement within two hours then initiate IV line.
To refer the client to the hospital for further management.








References
Smeltzer, C. S., Bare, B., Hinkle, J. L & Cheever, K. H. (2010). Brunner and Suddarths Textbook of Medical – Surgical Nursing (12th ed.) lippincott - Raven
Weber, J. & Kelly, J. (2010). Health Assessment in Nursing (4th ed.). Philadelphia: Wolters Kluwer/ Lippincott Williams & Wilkins.

Mashobeni South, Swaziland

Mashobeni  South, Swaziland ( Geo-location )

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MBABANE, SWAZILAND