Acute exacerbation of ulcerative colitis

Start with the easiest stuff first. That's probably going to be underlining all of the stuff that you think is abnormal. (If you go back to your original post and click on 'Edit' you can actually do the underlining so we can see and check it.)

Then get out your nursing diagnosis reference book, list some diagnoses that you think would be appropriate, and tell us why. Then we'll be able to provide feedback to you.

After you've completed those steps, you'll be well on your way.

You need to follow the steps of the nursing process in the sequence that they occur, specifically the first three steps to complete both of these case studies. Here are the steps:

1. Assessment (collect data from medical record, do a physical assessment of the patient, assess ADL's, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology)
2. Determination of the patient's problem(s)/Nursing diagnosis (make a list of the abnormal assessment data, match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use)
3. Planning (write measurable goals/outcomes and nursing interventions)

In order to accomplish determining the abnormal data in each case study you will need to look up information about the diseases of ulcerative colitis, chronic obstructive pulmonary disease and pneumonia. If you don't have books with this information, you will find it in the weblinks listed on this thread:

• http://allnurses.com/forums/f205/medical-disease-information-treatment-procedures-test-reference-websites-258109.html - Medical Disease Information/Treatment/Procedures/Test Reference Websites
  

As detailed in step #1, assessment, of the nursing process you want to learn about the signs, symptoms and pathophysiology of these diseases. That is how you will recognize the abnormal data that is listed in each of the case studies. Here is an older thread that has the pathophysiology of pneumonia: http://allnurses.com/forums/f205/pulmonary-tuberculosis-pneumonia-pathophysio-273191.html.

Nursing diagnoses (what your questions are calling NANDA bases) are patient problems that are identified by the nurse after assessing the patient and comparing the abnormal findings to what is considered to be normal. That is what you do in step #2 of the nursing process. You make a list of all the patient's abnormal data and match it with defining characteristics (the NANDA term for the symptoms of a nursing diagnosis) of any nursing diagnoses that apply to what is going on with the patient. When you are new at doing this it is best to use a nursing diagnosis reference book to help you out.

This is Maslow's Hierarchy for prioritizing nursing problems and the sequence you need to prioritize problems:

1. Physiological needs (in the following order)
   • the need for oxygen and to breathe [the brain gets top priority for oxygen, then the oxgenation of the heart followed by oxygenation of the lung tissue itself, breathing problems come next, then heart and circulation problems--this is based upon how fast these organs die or fail based upon the lack of oxygen and their function.]
   • the need for food and water
   • the need to eliminate and dispose of bodily wastes
   • the need to control body temperature
   • the need to move
   • the need for rest
   • the need for comfort
2. Safety and security needs (in the following order)
   • safety from physiological threat
   • safety from psychological threat
   • protection
   • continuity
   • stability
   • lack of danger
3. Love and belonging needs
   • affiliation
   • affection
   • intimacy
   • support
   • reassurance
4. Self-esteem needs
   • sense of self-worth
   • self-respect
   • independence
   • dignity
   • privacy
   • self-reliance
5. Self-actualization
   • recognition and realization of potential
   • growth
   • health
   • autonomy

Unless your instructors told you differently, I would make the top 2 priority diagnoses the same ones that are at the top of the list after sequencing them by Maslow's hierarchy.

Nursing interventions are done for the abnormal data that serve as the evidence supporting any nursing diagnosis. In other words, just like a doctor treats a patient's symptoms (abnormal data they have collected), so do we nurses. You will find these interventions in your nursing textbook. Use the index in the back of the book to find them if needed.

A case study is just another care plan but it is being done on a hypothetical patient. The purpose is for you to learn about the medical disease, how it is diagnosed and treated by the doctor as well as the nurse and to learn how to develop a nursing plan of care.

You might want to see the information on these threads as well:

• http://allnurses.com/forums/f50/help-care-plans-286986.html - Assistance - Help with Care Plans (in the General Nursing Discussion Forum)
  
• http://allnurses.com/forums/f205/care-maps-225330.html - Care Maps (in Nursing Student Assistance Forum)

Don't go to e-mail. Come back to allnurses to the thread and post that you started which is in the Nursing Student Discussion Forum. Click on the "Quote" button at the bottom right of your post and the text of your original post will come up in the reply box with [quotes] around it. Get rid of those [quotes] in brackets and then edit your original text using color.

1) Mrs Harriet Zoose, a patient admitted to a medical surgical nnit, has a medical diagnosis of acute exacerbation of ulcerative colitis. 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 say the colitis has drastically decreased her sex drive, which is causing tension within her marriage.
On the physical exam, you assess:
VS:
BP 90/5
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.

The questions are:

* Underline the data that is abnormal. I did it by high light the red color. So, please check if they are correct.
* Identify as many NANDA bases as you can and list them out. At least 5.----
* 1. Diarrhea
* 2. Body Temperature, Risk for imbalance
* 3. Pain, Chronic
* 4, Fatigue
* 5. Sexuality Patterns, ineffective.

List the diagnosis in order according to Maslow’s Hierarchy of Needs and identify the stages.
Diarrhea - Physiological needs (in the following order)

* the need for oxygen and to breathe [the brain gets top priority for oxygen, then the oxgenation of the heart followed by oxygenation of the lung tissue itself, breathing problems come next, then heart and circulation problems--this is based upon how fast these organs die or fail based upon the lack of oxygen and their function.]

Hyperthermia - the need to control body temperature
Pain, Chronic - the need for comfort
Fatigue - the need for rest
Sexuality Patterns, ineffective - Love and belonging needs intimacy

* Looking at your whole list, select the top 2 priorities nursing diagnosis.
* 1. Diarrhea
* Pain, Chronic

List at least three nursing interventions with rationales (cite your references), for each of the two priority nursing diagnosis that you identified.
I really don't know how to write these nursing interventions yet. So, take a look with what I got. Hope they are alright!!! Thanks



By looking at the whole picture. A complication of Ulcerative Colitits is Hemorrhage. If she has a BP of 90/50 and Pulse rate of 50 and blood in stool, she might be going into Shock. So your first priority would be Fluid Volume Deficit .

Best thing to do is look up information on Ulcerative Colitis it's complications, signs and symptoms....

I have this book by doenges nursing diagnoses it comes handy with nursing dx, interventions and rationales.

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:

1. Hyperthermia (supporting evidence: Temp 100.9, P 112 [tachycardia]) [need for control of body temperature]
2. 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.]
3. Acute Pain (supporting evidence: painful abdominal cramps, rates her discomfort level at 7 on a 10-point scale) [need for comfort]
4. 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]
5. 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]
6. 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:

1. Hyperthermia (supporting evidence: Temp 100.9, P 112 [tachycardia])
2. 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:

1. Assess/monitor/evaluate/observe (to evaluate the patient's condition)
2. Care/perform/provide/assist (performing actual patient care)
3. Teach/educate/instruct/supervise (educating patient or caregiver)
4. 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:

1. Assess and monitor:
   • record the patient's temperature every four hours
   • assess for other symptoms of fever: diaphoresis, chills and fatigue
2. 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
3. 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
4. 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).