[Verified Answer]: 6 2100 Neuro/Cognitive: Alert and oriented…

6 2100 Neuro/Cognitive: Alert and oriented to person, place, time, and situation. Gastrointestinal: BS present x 4 quadrants. Abdomen diffusely tender, distended. Last bowel movement x 1 day ago. +nausea/vomiting. Bilious colored emesis. Rates 9/10 constant epigastric pain. 06/06 2105 Situation: Ms. Sigmund is in room 5. She just checked in, and I performed her assessment. She is vomiting up bilious emesis about every 5 minutes. She is reporting 9/10 abdominal pain located in the epigastric region. Background: Ms. Sigmund is a 39-year-old female with a history of alcohol abuse and gallstones. She is a current everyday smoker. Assessment: Her abdomen is distended and tender. She has a fever of 101.1deg F. Other vital signs are all normal. Recommendation: I am requesting a prescription for pain and nausea medicine. I would like you to see the client as soon as you can step away. 06/08 0700 Nursing Note: Assumed care of client. Client lying down with HOB 30 degrees. Client is agitated and febrile. Alert and oriented to person and place. Client is reporting excessive thirst. Urine output 325 mL over past 24 hours. Tachycardia and tachypnea present. Breath sounds clear to auscultation. Blood pressure is hypotensive. Client rates pain at 9/10.