NUR 2180 Module 04 Lab Assignment Documentation of an Assessment of the Gastrointestinal System

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NUR:2180 Module 04 Lab Assignment Documentation of an Assessment of the Gastrointestinal System Crohn’s Disease Patient: Age: 20 Gender: Female Reason for visit: stomach pain, nausea, diarrhea ... 1. Health History 1. Any change in appetite? Loss? Yes, patient has a loss of appetite, she states that she has Crohn’s disease and when she has a flare up, she doesn’t feel like eating. 2. Any difficulty swallowing? No 3. Any foods you cannot tolerate? Patient is on a low-residue diet. 4. Any abdominal pain? Yes, patient states she has pain and cramping around her belly button and in her lower-right abdomen. Patient states she always has some pain and cramping but, the pain has gotten worse. Patient stated that for the past 2 days, she gets severe pain and has vomited about an hour or two after eating. The patient rates the pain around a 5 as long as they don’t eat. When the patient eats, the pain goes up to an 8/10 an hour or two after eating. It stays at an 8 for several hours. The pain is accompanied by nausea, sometimes vomiting and diarrhea. Patient states diarrhea is a 7 on the Bristol Stool chart. Stool is watery with no blood present. Vomiting is watery with a few larger pieces, no blood is present. The patient states that the things that make it better are not eating, using a heating pad and laying down. 5. Any nausea or vomiting? Yes, patient states she threw up a few times at home and feels nauseated. Her nausea increases after eating and she throws up sometimes. Ginger Ale helps her nausea so that she doesn’t throw up but, the nausea is still there. 6. How often are bowel movements? Patient states has 4 or more bowel movements a day 7. Any past history of GI disease? Yes, patient was diagnosed with Crohn’s disease in 2010. 8. What medications are you taking? Humira Pen 40mg/0.4 ml Budesonide EC 3mg capsule: 1 capsule 3x/day (Entocort) steroid Azathioprine 2 mg tablets: 1 tablet/day Dicyclomine 10 mg capsule: 1 capsule 3x/day Ondansetron ODT 8mg Tablets Dissolve 1 tab by mouth 3x/day as needed (for nausea) CHOLESTYRAMINE PACKET Powder in Packet: 1 Packet Mixed With Water Or Non-carbonated Drink Twice A Day As needed for diarrhea. Alprazolam 1mg tablets 1x/day Zolpidem Tartrate ER 6.5 mg Tablet : 1 tab at bedtime for sleep Ibuprofen 800 mg tablets: take 1 tablet 3x/day with food or milk as needed Bupropion HCL XL 300 mg tablets: 1 tablet/day Vitamin D3 50,000 unit capsules: 1x/week Multi-vitamins (OTC) 9. What have you eaten in the past 24 hours? Breakfast: plain toast and Grape Gatorade Snack: crackers Lunch: chicken noodle soup, crackers, Ginger ale Snack: pretzels Dinner: chicken noodle soup and crackers, Gatorade ll. Physical Examination A. Inspection Contour of abdomen: contour of abdomen is protuberant. Skin color and condition: skin is smooth and color is consistent with the rest of the body. No lesions were present. Patient has 2 scars from previous surgeries on Right Lower Quadrant. Pulsation or movement: no visible pulsation or movement Umbilicus: midline and inverted State of Hydration and nutrition: patient is dehydrated, poor nutrition Person’s facial expression and position in bed: patient is curled up on side in bed guarding the lower right side of their stomach and grimacing. Patient’s face is red, flushed and warm. B. Auscultation Bowel Sounds: Hyperactive bowel sounds Vascular sounds: no vascular sounds C. Percussion: The abdomen is t [Show More]

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