Module 6 Integrating

Integrating Instructions: Assignment #1 Abdomen Case Study

In this assignment, you will be tasked with completing a case study focused on abdominal issues. You will need to assess the patients condition, develop a problem list based on your findings, and propose a plan of care. Please follow the instructions below:

CASE STUDY ABDOMEN

J.P. 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 is 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 with regard to the abdominal pain?
3. From the readings, subjective data, and objective data, what is the most probable cause

of the abdominal pain?

1. Develop a problems list from the subjective and objective findings.
2. What should be included in the plan of care?
3. What interventions should be included in the plan of care for this patient?

Submission:

1. Compile your assessment, problem list, plan of care, and interventions into a coherent response. This can be submitted to your instructor.

Note: Ensure that your response is well-organized and adheres to any specific formatting or citation requirements provided by your instructor.