Question

Part 1

T.A. is a 50-year-old man who presents to the gastroenterologist with cramping and diarrhea.

Subjective Data
Pain level is a 6/10 location = right and left lower abdomen
Works as a union construction worker, has missed 1 day of work
States he has been going to the bathroom about 8 to 10 times a day for past 2 days
Appetite is decreased
PMH: Crohn’s disease, depression, anxiety

Objective Data
Vital signs: T 98.9, P 80, R 14, BP 120/68
Bowel sounds hyperactive in all four quadrants
Medications: Infliximab (Remicade) infusions every 6 weeks, fluoxetine (Prozac) 25 mg per day
Weight = 145 lbs., last visit weight = 152 lbs.

Questions

1. What other assessments should be included for this patient?
2. What questions should the nurse ask with regard to the abdominal pain?
3. From the readings, subjective data, and objective data, what is the most probable cause of the abdominal pain?
4. Develop a problems list from the subjective and objective findings.
5. What should be included in the plan of care?
6. What interventions should be included in the plan of care for this patient?

Answer 1

#The other assessment which has to be included for this patient are

• Any bleeding while passing stool
• Assess body temperature as patient can have fever due to infection
• Assess the nutritional status of the patient as diarrhoea due to lack of food intake or anorexia
• Assess the electrolyte level as diarrhoea can cause severe electrolyte imbalance
• Assess the weight if the patient. This is common due to loss of appetite, diarrhea
• Assess for signs and symptoms related to crohn's crisis

#In regards to the abdominal pain the nurse should ask about the type or nature of pain ,it's intensity and duration of pain .As this pain can be crampy and constant pain.

#The most probable cause of abdominal pain is the inflammatory process that happens in this disease condition in the gastrointestinal tract especially at the colon

#The problem listed based on the subjective and objective data are

• Acute abdominal pain
• Loss of appetite
• Diarrhea

#The plan of care should include the following

• Pain management
• Stopping diarrhoea
• Fluid replacement
• Electrolyte correction if any

#The intervention which should be included in the plan of care are

• Administration of medication as per order
• Administering intravenous fluid
• Monitoring vital signs
• Monitoring intake and output
• Provide nutritional rich foods