Reference no: EM133578026

Assignment: Nursing Care Plan

Nursing care plan on two diagnoses.

Patient male 52 DOB 9/25/1971

Chief complaint- coming home post op from colostomy 13 days ago 10/10 abd pain with blood noted in a colostomy bag. reported a fever of 101.5. Tachycardia hr in the 140s, initial bp 90s/40

History of present illness- 53 yr old male, diagnosed with rectal cancer awaiting chemotherapy, discharged from hospital on 10/26/23 to rehab after admission for an abscess of the gluteal region with malignant fistula and incontinence. The patient underwent bilateral dorsal transversus abdominis plane block with laparoscopic sigmoid loop colostomy creation. Presented to the emergency department from the rehab facility complaining of worsening foul smelling drainage through the gluteal region associated with pain

The first diagnosis is an abscess of the gluteal region with a malignant fistula.

The second diagnosis is rectal cancer. And the medication he is on is Cefepime, vancomycin for antibiotics and Dilaudid for pain.

This patient has no allergies.

Need to find

1) Nursing assessment plan
2) Nursing diagnosis for both medical diagnoses

Social history- Denies alcohol use, Substance abuse- Marijuana

Present History: Admitting Medical Diagnosis:

I. Why client is in hospital:

Medical diagnosis (does not include signs and symptoms)

II. Admitting Diagnosis Information:

This paragraph should describe what the signs and symptoms that caused patient to come to the hospital. It should not be what the doctor writes word for word. Paraphrase-put into your words. You may quote the patient.

III. Definition/Etiology/Pathophysiology:

This paragraph is to define and explain the admitting diagnosis/disease.

This paragraph should explain the etiology. The etiology is what causes the disease.

This paragraph should explain the pathophysiology of the patient's disease. Pathophysiology describes what the disease does to the body.

IV. Clinical Manifestations/Signs and Symptoms:

This/these paragraphs should explain what the textbook manifestations are and whethersigns and symptoms of the patient are similar or different.

V. Medical Management:

This/these paragraphs should explain the textbook medical management for the admitting diagnosis disease. What medical management is currently being done for the patient?

VI. Past History/Secondary Diagnosis:

Name an additional diagnosis that the patient has.

VII. Definition/Etiology/Pathophysiology:

Complete definition/etiology and pathophysiology for the secondary diagnosis as above.

VIII. Clinical Manifestations/Signs and Symptoms:

Complete clinical manifestations and signs and symptoms for secondary diagnosis as above.

IX. Medical Management

Complete the medical management of the secondary diagnosis as completed above.