Question

A 42-year-old patient with history of ulcerative colitis (UC) and anemia, went to the ED. While at the emergency room, he complaints of abdominal pain/swelling alongside blood in her stool which is watery which has been going on for some days now. Vital signs are (BP) of 90/56, heart rate (HR) 115 bpm, respiratory rate (RR) of 32, temperature of 101.9°F, oxygen saturation (O2 sat.) of 98% on room air, and a pain of 8/10 (using the verbal numeric pain scale) located in his left lower abdominal quadrant that is sharp, constant, and aggravated by movement. He states, “my stomach hurts so much I can barely take the pain”. he claims that he has been taking extra-strength Advil (ibuprofen 400mg) for the pain. His vitals were reassessed after 20 minutes showing a decrease in BP to 85/47, HR 130, RR 29, oral temperature of 101.9°C, O2 sat. 96%, and pain still at 9/10.

QUESTION

1. Which areas of our nursing assessment should we closely monitor and what are we looking for?
2. What are the major concerns with toxic megacolon related to bowel perforation?
3. What other possible diagnoses should be considered and ruled out?
4. What are the primary nursing diagnosis for this patient?

Answer 1

• We closely monitor

a.vital signs of the patient, if his vital signs are stable or not.

b.GI assessment should be done.

c.Intake output chart of the patient should be maintained.

d. Pain level of the patient should be assessed.

We should looking if the patient is suffering from any shock or anemia due to blood loss.

• Major concern with toxic megacolon ralated to bowel perforation is, If it is untreated it may cause whole body infection, bowel perforation may cause excessive bleeding, that leads to hypovolemic shock.

• Other possible diagnosis are.

a.peripheral arthritis.

b. Sacroiliitis

c. Finger clubbing.

d. Pyoderma gangrenosum.

e. Gallstones, kidney stones.

f. Liver disease.

g. Osteoporosis.

h. Thromboembolism.

• Nursing diagnosis.

a. Acute pain related to inflammation as evidenced by assessing pain level 8/10.

b. Imbalance nutritional status less than body requirements related to decreased absorption.

c. Impaired bowel elimination pattern related to watery stool as evidenced by assessing bowel elimination pattern.

d. Impaired thermoregulation pattern related to hyperthermia as evidenced by checking body temperature.

e. Impaired haemodynamic status related to hypotension as evidenced by checking blood pressure.