PMH of Crohn’s Disease and anxiety. PMH of Crohn’s Disease and anxiety. Justine Walsh, is a 45 year old female diagnosed with Crohn’s Disease. Patient admitted

PMH of Crohn’s Disease and anxiety.

PMH of Crohn’s Disease and anxiety.

Justine Walsh, is a 45 year old female diagnosed with Crohn’s Disease. Patient admitted through the Emergency Department with abdominal pain and hematochezia for 2 weeks. S/p hemicolectomy with a colostomy. Transferred to the medical/surgical unit for continued care and education. PMH of Crohn’s Disease and anxiety.

 

Personal/Social History:

Married with two young children. No history of smoking, alcohol or drug use.

 

RELEVANT Data from Present Problem: Clinical Significance:
 

 

 

 

 

 

 

 

 

 

 

RELEVANT Data from Social History: Clinical Significance:
 

 

 

 

 

PMH: Home Meds: Pharm. Classification: Expected Outcome:
  Pantoprazole (Protonix)

 

Lorazepam (Ativan)

1.

 

2.

 

1.

 

2.

 

 

 

Current VS: WILDA Pain Assessment (5th VS):
T: (oral) 99oF Words: sore
P: (regular) 88 Intensity: 4/10
R: (regular) 20 Location: At incision site
BP:142/88 Duration: surgery
O2 sat: 99% on RA Aggravate:

Alleviate:

Nothing

medication

 

 

What VS data is RELEVANT that must be recognized as clinically significant to the nurse?

RELEVANT VS Data: Clinical Significance:
 

 

 

 

 

Current Assessment:
GENERAL APPEARANCE: Resting in bed, appears in no acute distress
RESP: Nonlabored respiratory effort. Diminished breathe sounds bilateral LL.
CARDIAC: Pink, warm & dry, no edema, heart sounds regular with no abnormal beats, pulses strong, equal with palpation at radial/pedal/post-tibial landmarks
NEURO: Alert & oriented to person, place, time, and situation (x4)
GI: Abdomen soft, no bowel sounds audible per auscultation in all four quadrants. Abdomen tender to touch. Colostomy stoma beefy red.. Abdominal incision DSD intact, no drainage noted.
GU: Foley Catheter draining urine clear/yellow
SKIN: Abdominal incision, 14 staples, DSD C/D/I. Colostomy stoma protruding and beefy red.

 

What assessment data is RELEVANT that must be recognized as clinically significant to the nurse? PMH of Crohn’s Disease and anxiety.

RELEVANT Assessment Data: Clinical Significance:
 

 

 

 

 

 

 

 

 

 

 

Nursing Interventions: Rationale: Expected Outcome:
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Medical Management: Rationale for Treatment & Expected Outcomes

Care Provider Orders: Rationale: Expected Outcome:
1. OOB to chair x30 min. BID

 

2. NPO

 

3. NGT to low continuous suction

 

4. Accu check q6hr

 

5. Foley catheter

 

6. Strict I&O

 

7. DSD dressing change daily and prn to keep dry

 

8. Assess stoma qshift

 

9. PICC line care

   

 

PRIORITY Setting: Which Orders Do You Implement First and Why?

Order of Priority: Rationale:
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Medication Dosage Calculation:

Medication/Dose:

 

Mechanism of Action: Volume/time frame to Safely Administer: Nursing Assessment/Considerations:
PPN standard at 125ml/hr

 

 

 

 

 

Morphine 2mg IVP prn q4 hours for moderate pain

 

 

 

 

 

Cefazolin (Ancef) 2gm IVPB q12hours

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Lab Results:

What lab results are RELEVANT that must be recognized as clinically significant to the nurse?

Complete Blood Count (CBC:) Current: High/Low/WNL?
WBC (4.5–11.0 mm 3) 11.8  
Hgb (12–16 g/dL) 12  
Platelets (150-450 x103/µl) 245  
Neutrophil % (42–72) 43  
Band forms (3–5%) 4  

 

 

 

 

 

 

PMH of Crohn’s Disease and anxiety.

 

What lab results are RELEVANT that must be recognized as clinically significant to the nurse?

RELEVANT Lab(s): Clinical Significance:
 

 

 

 

 

 

Basic Metabolic Panel (BMP:) Current: High/Low/WNL?
Sodium (135–145 mEq/L) 136  
Potassium (3.5–5.0 mEq/L) 3.6  
Chloride (95–105 mEq/L) 96  
Glucose (70–110 mg/dL) 106  
Calcium (8.4–10.2 mg/dL) 8.5  
BUN (7–25 mg/dl) 9  
Creatinine (0.6–1.2 mg/dL) 0.8  

 

 

RELEVANT Lab(s): Clinical Significance:
 

 

 

 

 

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