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| No. 10 | 
Apr 26, 2008, 01:11 PM
 Re: Acute exacerbation of ulcerative colitis
[quote=Daytonite;2799592] A symptom is an objective observation you or someone else has made or a subjective perception made by the patient that serves as supporting evidence proving the problem exists. This evidence comes from the initial assessment that you have done of the patient that involves - collecting data data from the patient's medical record
- doing your own physical assessment of the patient
- assessing the patient's ability to perform ADL's (activities of daily living) which includes such things as bathing, dressing, transferring from bed to chair, walking, eating, toileting, grooming, ability to move and get where they need to go, communicate, sleep, and participate in diversional/social activities
- looking up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology - you need to know pathophysiology in order to understand the etiological links between nursing problems and medical diseases
Underline the data that is abnormal. - the blue highlight are things that were not abnormal data. I bolded in red what I would have underlined that you didn't. case study # 1 Mrs Harriet Zoose, a patient admitted to a medical surgical unit, has a medical diagnosis of acute exacerbation of ulcerative colitis (this is not a symptom, but a medical diagnosis). When obtain her health history, she tells you that she’s currently experiencing painful abdominal cramps and has had very frequent bowel movements containing blood and pus for the past few days. She rates her discomfort level at 7 on a 10-point scale. She also states she has recently had trouble sleeping and feels extremely fatigued. She says the colitis has drastically decreased her sex drive, which is causing tension within her marriage. On the physical exam, you assess: VS: BP 90/58 P 112 R 18 Temp 100.9 Hypoactive bowel sounds Abdominal distension and tenderness Pallor An upper GI series performed the previous day found scarred and stenotic bowel segments, which are obstruction the intestinal flow.
Identify as many NANDA bases as you can and list them out. At least 5. - all nursing diagnoses are chosen based upon the evidence that you have to support them. This the list of symptoms you have to work with: - painful abdominal cramps
- frequent bowel movements containing blood and pus for the past few days
- rates her discomfort level at 7 on a 10-point scale
- recently had trouble sleeping
- feels extremely fatigued
- has drastically decreased her sex drive, which is causing tension within her marriage
- BP 90/58
- P 112
- Temp 100.9
- Hypoactive bowel sounds
- Abdominal distension and tenderness
- Pallor
- scarred and stenotic bowel segments
Nursing diagnoses you came up with:- Diarrhea (supporting evidence: painful abdominal cramps)
- Body Temperature, Risk for imbalance (supporting evidence: Temp 100.9)
- Chronic Pain (supporting evidence: painful abdominal cramps, rates her discomfort level at 7 on a 10-point scale)
- Fatigue (supporting evidence: has drastically decreased her sex drive)
- Sexuality (supporting evidence: has drastically decreased her sex drive)
I've been re-thinking the statement "identify the NANDA bases" in your directions. The NANDA diagnoses are classified into domains and classes. The classes were originally based on Gordon's 11 Functional Needs. That might be the bases you are to identify, so I am including that information as well. That information is only going to be found in NANDA-I Nursing Diagnoses: Definitions & Classification 2007-2008published by NANDA International or information your instructors might have given you. Diarrhea belongs in the functional domain; class of elimination. Body Temperature Risk for Imbalance belongs in the physiological domain; class of physical regulation. Chronic Pain belongs in the functional domain; class of comfort. Fatigue belongs in the functional domain; class of activity/exercise. Sexuality belongs in the functional domain; class of sexuality. I'm diagnosing the following NANDA diagnoses and listing them in order according to Maslow’s Hierarchy of Needs and identifying Maslow's stage:- Hyperthermia (supporting evidence: Temp 100.9, P 112 [tachycardia]) [need for control of body temperature]
- Ineffective Sexuality Pattern (supporting evidence: has drastically decreased her sex drive which is causing tension within her marriage) [physiological need for sexual release - I know it's not listed on the chart I posted. This could also possibly be classified as a need for love and belonging which would sequence it below he diagnosis of Anxiety.]
Acute Pain (supporting evidence: painful abdominal cramps, rates her discomfort level at 7 on a 10-point scale) [need for comfort] Anxiety (supporting evidence: BP 90/58 [hypotension], P 112 [tachycardia], recently having trouble sleeping, feeling extremely fatigued, tension in the marriage) [need for safety from psychological threat] Risk for Deficient Fluid Volume (frequent bloody bowel movements for the past few days, pallor, supporting evidence: hypoactive bowel sounds, abdominal distension and tenderness) [potential need for food and water] Risk for Injury [perineal sepsis, ileus] (supporting evidence: frequent bowel movements containing blood and pus for the past few days, scarred and stenotic bowel segments) [potential need for protection] Hyperthermia belongs in the physiological domain; class of physical regulation. Ineffective Sexuality Pattern belongs in the functional domain; class of sexuality. Acute Pain belongs in the functional domain; class of comfort. Anxiety belongs in the psychosocial domain; class of emotional. Risk for Deficient Fluid Volume belongs in the physiological domain; class of fluid & electrolyte. Risk for Injury belongs in the environmental domain; class of risk management. My two priority diagnoses would be: - Hyperthermia (supporting evidence: Temp 100.9, P 112 [tachycardia])
- Acute Pain (supporting evidence: painful abdominal cramps, rates her discomfort level at 7 on a 10-point scale)
List at least three nursing interventions with rationales (cite your references), for each of the two priority nursing diagnoses that you identified. - I'm only doing one just so you get an idea of what you need to do.Hyperthermia - NANDA's definition of hyperthermia is body temperature elevated above normal range. (page 108, NANDA-I Nursing Diagnoses: Definitions & Classification 2007-2008). Normal range is from 96.8 to 99.5 (oral), 97.3 to 100.2 (rectal), and 97.2 to 100 (tympanic). [page 40, Expert 10-Minute Physical Examinations] Nursing interventions are of 4 general types. They: - Assess/monitor/evaluate/observe (to evaluate the patient's condition)
- Care/perform/provide/assist (performing actual patient care)
- Teach/educate/instruct/supervise (educating patient or caregiver)
- Manage/refer/contact/notify (managing the care on behalf of the patient or caregiver)
So. with those guidelines in mind, here are nursing interventions for hyperthermia. These are only examples. You may want to amend some of them based on reference information you are able to find to support any intervention:- Assess and monitor:
- record the patient's temperature every four hours
- assess for other symptoms of fever: diaphoresis, chills and fatigue
- Patient care interventions:
- increase fluids and provide a high nutritional diet
- keep the room at a stable environmental temperature
- provide linen and gown changes as necessary for patients who are diaphoretic
- give antipyretics as ordered by the doctor
- Teach the patient
- the importance of increasing fluid intake
- the proper dose of the antipyretic they are to take and any side effects to watch for
- Notify the physician for a fever that is persistently over 102 and/or not responding to antipyretics (there may be doctor's orders or a facility policy for this).
For the acute Pain I have it as follow: Acute Pain - The state in which an individual experiences and reports the presence of severe discomfort or an uncomfortable sensation lasting from 1 second to < 6 months.
1. Observe and monitor: - Acknowledge the presence of the pain
- Listen to attentively concerning the pain.
2. Patient care Interventions: - Provide the patient with opportunities to rest during the day and with the periods with uninterrupted sleep at night (Must rest when pain is decreased.
- Discuss with the patient and her husband the Therapeutic Uses of Distraction as well as other methods of Pain relief.
- Promote relaxation with a back rub, massage, or warm bath.
- give tyrenol as ordered by the doctor.
3. Teach the patient - the proper dose of tylenol they are to take and any side effects to watch for.
- Teach the method of Distraction during Acute Pain that is not a burden (e.g., count items in a picture; count anything i nthe room, such as patterns on wallpaper; count silently to self; breathe rhythmically; listen to music, and increase the volume as the pain increase.)
- Teach a specific realxation strategy (e.g.,slow, rhythmic breathing or deep breath-clench fists-yawn)
4. Notify the physician for a pain thati spersisitently or not responding to painkiller. 
__________________________________________  | | Advertisement Sponsored Links | | | | No. 11 |
Apr 26, 2008, 03:22 PM
Sounds good to me. You only need 3 interventions with rationales though. I didn't list rationales. Your interventions should address the symptoms (supporting evidence). You should be able to find them in your nursing textbooks. Use the index at the back of the books if you need to.
For Acute Pain where the supporting evidence is - painful abdominal cramps
- rates her discomfort level at 7 on a 10-point scale
Appropriate interventions would be - Acknowledge the presence of the pain. [addresses the issue of the presence of pain] (Rationale: Accepting what a patient tells you is an effective communication technique that helps to build trust in the relationship with the patient.)
- Place the patient in a semi-Fowler's or Fowler's position. [addresses the abdominal cramps] (Rationale: Increased angle reduces the stress on the abdominal organs.)
- Give Tylenol as ordered by the doctor. [addresses the actual level of pain of 7 on a 10-point scale] (Rationale: Nonopioid analgesics are used to relieve mild to moderate pain and pain associated with inflammation.)
Again, you can choose any three interventions you like. I have no idea what your instructors are looking for.
The reason I used the diagnosis of Acute Pain was because the scenario did not specify the length of time that the patient had been having this pain. The reason I did not use a diagnosis of Diarrhea was because the scenario mentioned nothing about diarrhea or loose stools and I didn't want to assume that this was happening.
| | No. 12 |
Apr 26, 2008, 03:53 PM
Re: Acute exacerbation of ulcerative colitis
Hi Daytonite,
I just finished my other assignment that will due this Monday. Could you please have a look if I need to improve with any details. Because of your given info. For this one I think it is easier than the casestudy 1 & 2.
A 1000 thanks.  Instructions: - Underline abnormal signs and symptoms
- Above abnormal data, Write O, if objective data and S, if subjective data.
- Cluster data into related groups to identify and support each problem
- Label actual and risk problems using NANDA nursing diagnoses( include related to, as evidenced by, or risk factors, as appropriate)
General Info. Provide by Client: Mrs. Janice Watson. 46 years old, Female, Caucasian Admission Date/ Time; March 15,1999; 9:00 a.m. Admitting Medical Diagnosis: Intractable Vomiting, Dehydration Arrived on Unit by : Wheelchair, from emergency department Admitting Weight/ Vital signs: T 99 , P 76, R 20, BP 112/78; weight 145 pounds, height 5’3”. Clien’s Perception of reason for admission: Client states she has had nausea and vomiting for 4 days. Allegies: no know allergies ( NKA) Medications: no presceiption medications; she took “Pepto-Bismol, but I can’t keep it down” Assessment data: Oxygenation : Reports no difficulty breathing; respirations twenty per minute. States she is a nonsmoker. Breath sounds are clear to auscultation bilaterally; no cough. Apical pulse 76, strong and regular; radial pulses are equal in strength and quality, however, easily obliterated. Pedal pulses are regular and equal in strength. Denies any chest pain. Brisk capillary refill of fingernail beds. No pedal, ankle, or leg edema noted. Temp: 99.0 F, denies having any fever over last few days Nutritional / Fluid: She has an IV for hydration and electrolyte replacement in her right forearm. 5’3” height, 145 pounds; weight has been relatively stable, until now. Reports weight loss of about 5 pounds since she became ill. States, “ I haven’t been able to eat for 4 days.” Reports she normally eats two regular means each day and has not been dieting. She complains of generalized abdominal cramping and is nauseated now. “I was trying to vomit in the emergency department, but there’s just nothing in my stomach.” Her skin turgor is inelastic, oral mucous membranes pink, but sticky. GI/ Elimination : Reports last bowel movement was two days ago; no diarrhea. Normal pattern is one bowel movement everyday; states she urinated once yesterday. Abdomen is slightly distended and tender to palpation. Bowel sounds are present, but hypoactive. Rest/ Sleep: She state she has no difficulty sleeping at home, before she became ill. Denies use of sleeping aids or medications. Pain Avoidance: Generalized abdominal cramping, described as sharp, intermittent, and rated as “six” on scale of one to ten. Nurse observes client holding her abdomen and stomach region. Sexuality / Reproductive: Menstrual periods are usually regular, every twenty-eight days. Clients reports she had a tubal ligation after the birth of her second child about twenty years ago. Denies any concerns with sexual aspect of her life. Activity: States she is active and has no problem. Client reports no aerobic activity, walks occasionally. Works as legal secretary for a well-known attorney. Enjoys going to the theatre with her husband and reading in her spare time. Additional Data: The client is alrert and oriented; responds appropriately to questions. Her eyes have a sunken appearance. Denies visual or auditory problems. The clients’ skin is intact, warm, and dry. Her hands tremble and she states, “Just leave me alone. I don’t want to move.” Abnormal Subjective Data: - Nausea and vomiting for 4 days
- Complains of generalized abdominal cramping and is nauseated now.
- Reports last bowel movement was 2 days ago, no diarrhea.
- Urines once yesterday.
- Generalized abdominal cramping, described as sharp, intermittent, and 6 on scale of one to ten.
- States to just leave her alone. She doesn’t want to move.
Abnormal Objective Date: - Redial pulses is easily obliterated.
- Her skin turgor is inelastic
- Oral mucous membrane is sticky
- Abdomen is slightly distended and tender to palpation.
- Hypoactive bowel sounds
- Client holding her abdomen and stomach region.
- Her hands tremble.
Cluster data into groups of related data to determine problem. Cramping/ Pain - Complains of generalized abdominal cramping and is nauseated now.
- Generalized abdominal cramping, described as sharp, intermittent, and 6 on scale of one to ten.
- States to just leave her alone. She doesn’t want to move.
- Abdomen is slightly distended and tender to palpation.
- Hypoactive bowel sounds
- Client holding her abdomen and stomach region.
- Her hands tremble.
Fluid/ Nutrition- Nausea and vomiting for 4 days
- Reports last bowel movement was 2 days ago, no diarrhea.
- Urines once yesterday.
- Her skin turgor is inelastic
- Dry skin and oral mucous membrane is sticky
Determine NANDA nursing diagnosis. - Constipation R/T inadequate fluid intake AEB reports last bowel movement was two days ago.
- Fluid Volume Deficit R/T vomiting/ nausea AEB dry skin and sticky oral mucous membrane, Urines once yesterday.
- Acute Pain R/T impair comfort AEB abdominal cramping, sharp, intermittent and rated as 6 on a 10-point scale.
- Disturbed sleep Pattern R/T pain AEB abdominal cramping.
- Nausea R/T sick to the stomach AEB Nausea and vomiting for 4 days and weight loss 5 pounds and haven’t been able to eat for 4 days.
Please advice. thanks | | No. 13 |
Apr 27, 2008, 01:48 AM
My corrections or additions are in red or blue.Abnormal Subjective Data:- Nausea and vomiting for 4 days
- Complains of generalized abdominal cramping and is nauseated now.
- Reports last bowel movement was 2 days ago, no diarrhea.
- Urines once yesterday.
- Generalized abdominal cramping, described as sharp, intermittent, and 6 on scale of one to ten.
- States to just leave her alone. She doesn’t want to move.
- Reports weight loss of about 5 pounds since she became ill.
- “ I haven’t been able to eat for 4 days.”
Abnormal Objective Data:- Redial pulses is easily obliterated.
- Her skin turgor is inelastic
- Oral mucous membrane is sticky
- Abdomen is slightly distended and tender to palpation.
- Hypoactive bowel sounds
- Client holding her abdomen and stomach region.
- Her hands tremble.
- Eyes have a sunken appearance.
Cluster data into groups of related data to determine problem.
Cramping/ Pain - Complains of generalized abdominal cramping and is nauseated now.
- Generalized abdominal cramping, described as sharp, intermittent, and 6 on scale of one to ten.
- States to just leave her alone. She doesn’t want to move.
- Abdomen is slightly distended and tender to palpation.
- Hypoactive bowel sounds
- Client holding her abdomen and stomach region.
- Her hands tremble.
Fluid/ Nutrition- Nausea and vomiting for 4 days
- Reports last bowel movement was 2 days ago, no diarrhea.
- Urines once yesterday.
- Her skin turgor is inelastic
- Dry skin and oral mucous membrane is sticky
Determine NANDA nursing diagnosis.- Constipation R/T dehrdration, inadequate fluid intake AEB reports last bowel movement was two days ago.
- Fluid Volume Deficit R/T fluid volumn loss AEB vomiting x 4 days, inelastic skin torgor, dry skin and sticky oral mucous membrane, Urinated only once yesterday.
- Acute Pain R/T impair comfort AEB abdominal cramping, sharp, intermittent and rated as 6 on a 10-point scale. - wouldn't use
- Disturbed sleep Pattern R/T pain AEB abdominal cramping. - she said she didn't have any trouble sleeping
- Nausea R/T sick to the stomach AEB Nausea and vomiting for 4 days and weight loss 5 pounds and haven’t been able to eat for 4 days. - wouldn't use since the patient is already reporting vomiting
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