What should be included in the plan of care

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Reference no: EM133867558

Assignment:

J.D. 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 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

Questions:

1. What other assessments should be included for this patient?

2. What questions should the nurse ask in relation to the abdominal pain?

3. From the readings and subjective 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?

Reference no: EM133867558

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