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J.S. is a 52 year old female who is presenting in the ER with frequent bloody...

J.S. is a 52 year old female who is presenting in the ER with frequent bloody stools. J.S. has a history of ulcerative colitis, DM II, CAD, HTN, & hypercholesterolemia. Patient presents pale, short of breath and fatigued. Vitals: T- 99.6 RR- 18 HR- 98 BP-146/76 O2Sat- 93% on room air Develop a care plan for J.S.

1. POTENTIAL HEALTH DEVIATIONS, PREDISPOSING AND RELATED FACTORS AT LEAST 2 - "AT RISK FOR...")

2. INTER-PROFESSIONAL CONSULTS, (INCLUDE DIET, TEST, TREATMENTS) WITH RATIONAL SUPPORTED WITH EVIDENCE BASED CITATIONS.

3. Relevant diagnostic procedures and pertinent lab tests

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Answer #1

1.Diarrhoea related to inflammation or irritation of bowel as evidenced by hyperactive bowel sound

Here patient has complaints of frequent bloody stool. It is a clinical features of ulcerative colitis

Outcome : Report reduction in frequency of stools, rectum to more normal stool consistency.

Intervention

  • Ascertain onset and pattern of diarrhoea
  • Observe and record stool frequency, characteristics and precipitating factors.
  • Promote bed rest.
  • Provide commode
  • Offer clear liquid hourly, avoid cold fluids
  • Administer medication as prescribed

2. Risk for decreased fluid volume related to diarrhoea.

Outcome ' Maintain adequate fluid volume

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