Name: Mya Partner
Age: 21 years
Sex: Female
Physician: Dr. B.Goodwell
SUBJECTIVE
Laying on left side, crunched up. Able to sit up at times, but keeps holding abdomen. Pain in the right lower quadrant of abdomen, starting 2 days ago. Gradual onset. 8/10. Right lower quadrant, 10/10 with palpation. Nausea. No vomiting, no diarrhea, no constipation. Hot and cold since this morning.
Gravida 1, Para 1, Child 2 and well. Last PAP 2 weeks ago- hasn’t herd back.
LMP 3 weeks ago. 5 days long. Not heavy. No clots, no spotting or bleeding since. Sexually active. 1 partner. Condoms for prophylaxis.
Past Medical History HVP- at 16, no irregular PAP, removal with “freezing”
No medications
Past Surgical History NIL
Family History Mum and dad are both well
Childhood Illness Chicken pox as child, was immunized fully
OBJECTIVE
VITALS: Temp 38.3 C, Pulse 100 bpm, BP 130/90, RR 17, 02- 98% on RA
Skin hot and slightly diaphoretic. Cap refill < 2 seconds.
INSPECTION: Abdomen flat. No bruising or discoloration, No scars lesion, or moles.
AUSCULATAION: Bowel sounds in all 4 quadrants, regular 20 per minute.
PERCUSSION: Percussion tympanic across abdomen.
PALPATION: No masses palpated on light or deep palpation.
Pain on palpation of RLQ. Radiating into umbilicus at times. Worse on rebound
- Identify one priority NANDA diagnosis.
Risk for Constipation as evidenced by abdominal pain, lack of mobility due to the pain and no vomiting, diarrhea or constipation
