Question

Part 1

J.P. 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:

a. What other assessments should be included for this patient?

b. What questions should the nurse ask with regard to the abdominal pain?

c. From the readings, subjective data, and objective data, what is the most probable cause of the abdominal pain?

d. Develop a problems list from the subjective and objective findings.

e. What should be included in the plan of care?

f. What interventions should be included in the plan of care for this patient?

Answer 1

a)

• Assessing malaise, fever and weight loss
• Extraintestinal manifestations involving the eye, joints, skin and oral cavity: inflammation of eye, joints, skin
• Assessment for any mouth sores
• Pain or drainage near or around the anu-s
• Mayo score which consists of the macroscopic findings at endoscopy, plus clinical manifestations such as stool frequency, rectal bleeding. A Mayo score of six or more indicates moderate-to-severe ulcerative colitis is present
• As Crohn’s disease can extend above the terminal ileum beyond the reach of a colonoscope, radiological assessment is helpful.
• Endoscopy investigations, such as colonoscopy and sigmoidoscopy.
• Pelvic ultrasound;
• Barium studies;
• Computerised tomography scans;
• Magnetic resonance imaging scans;
• Capsule endoscopy, which involves swallowing a wireless video capsule that travels through the gastrointestinal tract to access areas that are difficult to reach by endoscopy.
• Blood tests;

b)

• Does the pain occur after eating meals and is it relieved by opening the bowels?
• Is the abdominal pain crampy?
• Where is the pain more concentrated around?
• Is there any abdominal swelling or bloating during the pain?

c) Abdominal pain coupled with unintentional weight loss can be due to a variety of conditions :

• parasitic infection, such as amebiasis or hookworms
• peptic ulcer
• viral gastroenteritis (stomach flu)
• certain bacterial infections involving either the intestines or solid organs
• colitis
• Crohn’s disease
• depression, stress, or anxiety

d)

• Diarrhea related to Inflammation, irritation, or malabsorption of the bowel
• Risk for Deficient Fluid Volume related to Excessive losses through normal routes (severe frequent diarrhea, vomiting)
• Acute Pain related to Hyperperistalsis, prolonged diarrhea, skin/tissue irritation, perirectal excoriation, fissures, fistulas
• Imbalanced Nutrition: Less Than Body Requirements related to Altered absorption of nutrients
• Anxiety related to Physiological factors/sympathetic stimulation (inflammatory process)

e)

• Identify healthy ways to deal with and express anxiety.
• Appear relaxed and able to sleep/rest appropriately
• Relief of abdominal pain
• Demonstrate stable weight or progressive gain toward goal with normalization of laboratory values and absence of signs of malnutrition.
• Reduction in frequency of stools, return to more normal stool consistency.
• Maintain adequate fluid volume as evidenced by moist mucous membranes, good skin turgor, and capillary refill; stable vital signs; balanced I&O with urine of normal concentration/amount.

f)

• Administer parenteral fluids, blood transfusions as indicated.
• Monitor laboratory studies such as electrolytes (especially potassium, magnesium) and ABGs (acid-base balance).
• Maintain oral restrictions, bedrest; avoid exertion.
• Weigh daily.
• Identify and restrict foods and fluids that precipitate diarrhea (vegetables and fruits, whole-grain cereals, condiments, carbonated drinks, milk products).
• Restart oral fluid intake gradually. Offer clear liquids hourly; avoid cold fluids.
• Observe for fever, tachycardia, lethargy, leukocytosis, decreased serum protein, anxiety, and prostration.
• Encourage patient to assume position of comfort (knees flexed).
• Provide comfort measures (back rub, reposition) and diversional activities.
• Cleanse rec-tal area with mild soap and water or wipes after each stool and provide skin care
• Provide sitz bath as appropriate.
• Encourage verbalization of feelings. Provide feedback
• Acknowledge that the anxiety and problems are similar to those expressed by others. Active-Listen patient’s concerns.
• Provide a calm, restful environment.
• Assist patient to learn new coping mechanisms (stress management techniques, organizational skills).
• Help patient identify and initiate positive coping behaviors used in the past.
• Recommend rest before meals.
• Provide oral hygiene.
• Avoid or limit foods that might cause or exacerbate abdominal cramping, flatulence (milk products, foods high in fiber or fat, alcohol, caffeinated beverages, chocolate, peppermint, tomatoes, orange juice).
• Promote patient participation in dietary planning as possible.
• Record intake and changes in symptomatology.