course material

1. PMH of Crohn’s Disease and anxiety.
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: ORDER NOW FOR CUSTOMIZED, PLAGIARISM-FREE
PAPERSPMH: 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:soreP: (regular) 88 Intensity:
4/10R: (regular) 20 Location: At incision siteBP:142/88 Duration:
surgeryO2 sat: 99% on RA Aggravate:Alleviate: Nothingmedication 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 distressRESP: 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 landmarksNEURO: 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/yellowSKIN:
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 OutcomesCare 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

2. 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: