Question

Mr. Garcia is a 70 year old male and who fell in front of his house while walking his dog. He sprained his left knee. His initial treatment included an Ace bandage wrap, ice, and Motrin 200 mg for pain as needed. He was instructed to elevate his leg for the next 4 days. He is being seen as a follow up visit and reports that his knee feels much better, but he has abdominal discomfort. When questioned about the problem, he states, "A couple of days ago, my stomach started to feel a little funny, almost like a slight ache." To further questioning he replied, "My bowel movements have been like little pebbles the last 4 days." He denies any problem with elimination prior to this and says, "I usually have a bowel movement after breakfast and it usually a bit softer in consistency" When asked how he has spent his time recently, he stated that he has been "trying to stay off my knee as much as I can. I haven't been able to walk my dog which upsets me. I even avoid going to the bathroom by not drinking as much water during the day." The physical assessment was conducted and the following were found: bowel sounds were active in all quadrants, percussion revealed dullness in the right lower quadrant, the abdomen was slightly distended and non-tender, and there were dry feces in the rectum 1. ASSESSMENT a. List all the data Mrs. Jacob told the nurse (subjective data). b. List all the physical findings (objective data) 2. CREATING THE DIAGNOSIS a. Analysis of the data in comparison with normative data b. Cluster pertinent information

Answer 1

ANSWER :

1.ASSESSMENT :

a. Stomach ache, decreased bowel movements, Abdominal discomfort

b. Active bowel movements, Dullness in right lower quadrant of abdomen during percussion, Abdominal distension, and presence of dry feces in the rectum.

2. CREATING THE DIAGNOSIS :

a. Analysis of data is made to follow a certain goal of useful information conclusions and decision making.On the other hand normative data is that which establishes a basic distribution of score against the score which can be measured. Normative data is obtained from large selected samples from wider areas.

b. Cluster pertinent information uses the quality methods depending on similar measures which are are used by its method and implementation .

c. NURSING DIAGNOSIS :

  1. Constipation related to decreased dietary intake as evidenced by difficulty in passage of feces.

2. Disturbed sleeping pattern related to abdominal discomfort as evidenced by restlessness.

3. Acute pain related to abdominal pain as evidenced by discomfort.

3. PLANNING :

a. To improve bowel normal bowel functioning

b. * Auscultate bowel sounds using percussion method

* Encourage patient to take sufficient fluid intake

* Educate to avoid gas forming food substances

* Use stool softeners for free stool passage.

c. * Involve family members in treatment plan of patient

* Address family support, physician consultation, self confidence for patient care.

* Provide a environment which is safer to patient during pain.