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My patient is now back in his work and has no more complaints of abdominal pain recurrence. I couldn’t get his final diagnosis because I couldn’t read the physician’s handwriting, neither the ER nurse. The patient was diagnosed with “dyspepsia”.

The basic function of a nurse is to conduct thorough assessment not only at the time the patient has complaints, but throughout the entire shift. That is to monitor the patient’s condition, sick or well. As an initiative, I assessed the said patient thoroughly. Part of which is the gathering of necessary information that will be useful and of great importance in the continuity of nursing care delivery or in quality nursing management. Upon the patient’s complaint of no relief from the antacid, further assessment was made and an ongoing nursing management was rendered.

In my observations, I can see that the patient’s condition was aggraviated and it was confirmed when the patient verbalized that the pain became more intense and that it made him weaker. Since we have no doctor-on-duty that night, I advised the patient to consult a doctor at once in order to seek medical advice and for him to undergo thorough evaluation. The patient agreed to go to the hospital and since he had no significant others around, I ushered him the hospital agreed by the patient. He was then entertained in the ER and laboratory work-ups were made. Patient was given medications and was made comfortable while waiting for the laboratory results. Everything in his CBC were just within the normal limits, as well as his stool exam and urinalysis. The doctor just said that the patient’s abdominal pain is due to indigestion.

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