Question

J. P. is a 50-year-old man who presents to the gastroenterologist with cramping and diarrhea. Subjective Data Pain level is a 6 out of 10; pain is located in the right and left lower abdomen. Works as a union construction worker, has missed one day of work. States he has been going to the bathroom about 8–10 times a day for past two days. Appetite is decreased. PMH: Crohn's disease, depression, anxiety. Objective Data Vital signs: Temperature: 37° C. Pulse rate: 80 beats per minute. Respiration: 14 breaths per minute. Blood pressure: 120/68. Bowel sounds hyperactive in all four quadrants. Medications: Infliximab (Remicade) infusions every six weeks, fluoxetine (Prozac) 25 mg per day. Weight: 145 pounds. Weight last visit: 152 pounds. Initial Posting For this discussion's initial post, address the following: What other assessments should be included for this patient? What questions should the nurse ask with regard to the abdominal pain? From the readings, subjective data, and objective data, what is the most probable cause of the abdominal pain? Why? Develop a problems list from the subjective and objective findings. What should be included in the plan of care? What interventions should be included in the plan of care for this patient?

Answer 1

What other assessments should be included for this patient? 1. Head to food assessment 2. Cardiac assessment 3. Abdominal assessment 4. Mini mental status examination What questions should the nurse ask with regard to the abdominal pain? The time of the pain should be noted. 1. Abdominal pain occur is it before eating or after eating 2. Do u have pain early in morning or late night. From the readings, subjective data, and objective data, what is the most probable cause of the abdominal pain? Why? Pain assessment made with objective data, with Crohn's diseases. Crohn's disease is caused by the inflammation in the digestive track. This disease leads to the severe diarrhea, fatigue, and abdominal pain.

Develop a problems list from the subjective and objective findings 1. Right and left lower abdominal pain 2. Anorexia 3. Hyperactive bowel movement 4. Diarrhea 8-10 times a day What should be included in the plan of care? 1. Fluid volume deficit related to diarrhea 2. Altered nutritional status related to diarrhea, anorexia 3. Impaired skin integrity due to dehydration What interventions should be included in the plan of care for this patient? 1. The oral fluids consumption should be more 2. Intravenous fluids are given if necessary 3. Pain management 4. Proper skin care 5. Psychological support and counseling