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 disease, depression, anxiety
Objective Data
Vital signs: T 37 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, last visit weight = 152
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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?
SAMPLE SOLUTION
Other Assessments
There are many assessments that can be included in the case study | GET AN EXPERT FOR YOUR ASSIGNMENT | assessments are: undertaking a cardiac assessment, assessing the abdomen, doing a head to foot assessment and if possible, a cardiac assessment.
Questions to Be Asked
Abdominal pains are common among patients of J. P’s nature. Some of the abdominal inspections to be undertaken should include palpation and percussion and auscultation and general | GET AN EXPERT FOR YOUR ASSIGNMENT | undertaken, however, some of the questions the nurse can ask are: whether the pains happen before or after eating and secondly whether it occurs early morning or late at night.
Possible Causes of Pain
Based on initial assessment and objective data, J.P’s possible cause of pain is prolonged instances of diarrhea that has left him drained and lost weight. It is also possible that the pain comes as a result of the inflammatory bowel or the obstruction of…
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