ASSESSMENT:
Sbujective
1) PMH- cystic fibrosis, Cholecystitis, autoimmune pancreatitis, episodes of acute pancreatitis, biliary tract disease, abdominal trauma, metabolic disorders, infecction, duodenal ulcers, Cancer: ampulla of vater, duodenum, and pancreas.
2) Nutritional metabolic functional pattern- N&V, anorexia
3) Health perception- fatigue, alcohol abuse (number one cause)
4) Exercise- dyspnea
5) Cognitive-perceptual-(may have no pain 0 of 1-10 scale) P:eating, alcohol, Q: sharp, R: radiate to the back, flank, S: severe abdominal, LUQ or midepigastic, T: intensity change with time
6) Medications: NSAID, Thiazides
7) Surgical history: ERCP, pancreas, duodenum, biliary tract, and/or stomach
Objective
Restless, anxiety, low grade fever;
Malabsorption, weight loss; tachypnea, tachycardia; abdominal distention and tenderness, jaundice; decreased bowel sounds, steatorrhea, urine dark brown/frosty.
-