Kevin Valeri is a 64-year-old man who presents to the gastroenterologist\u2019s office with constipation and abdominal bloating.<\/p>\n
Subjective Data<\/p>\n
Pain level is a 4\/10 location = right lower abdomen
\nRetired Engineer
\nStates he has been going to the bathroom with the help of laxatives, but not having regular movements
\nAppetite is decreased, some nausea
\nPMH: depression, anxiety, chronic constipation<\/p>\n
Objective Data<\/p>\n
Vital signs: T 37 degrees Centigrade, P 64, R 16, BP 124\/58
\nBowel sounds hypoactive in all four quadrants
\nMedications: Lamictal 200mg daily, Lexapro 10 mg daily
\nWeight = 210 lbs, last visit weight = 195
\nWhat other assessments should be included for this patient?
\nWhat questions should the nurse ask with regard to the abdominal pain?
\nFrom the readings, subjective data, and objective data, what is the most probable cause of the abdominal pain?
\nWhat should be included in the plan of care?
\nWhat interventions should be included in the plan of care for this patient?
\nAPA FORMAT
\nREFERENCE REQUEIRED: <\/p>\n
Jarvis, C. (2016). Physical examination & health assessment (7th ed.). Philadelphia, PA: Saunders.<\/p>\n
Chapter 21: Abdomen
\npp. 537\u2013566 (Structure, Function, Subjective and Objective Data, Documentation and Critical Thinking)
\nChapter 24: Male Genitourinary System
\npp. 691\u2013710 (Structure, Function, Subjective and Objective Data, Documentation and Critical Thinking)
\nChapter 25: Anus, Rectum, and Prostate
\npp. 721\u2013731 (Structure, Function, Subjective and Objective Data, Documentation and Critical Thinking)
\nChapter 26: Female Genitourinary System
\npp. 737\u2013763 (Structure, Function, Subjective and Objective Data, Documentation and Critical Thinking)<\/p>\n
___________________
\nOther assessments that should be included for this patient are:
\nA thorough abdominal examination, including inspection, auscultation, percussion, and palpation.
\nA rectal examination to assess for any masses, fecal impaction, or other abnormalities.
\nA review of the patient’s medication list to identify any medications that may contribute to constipation or abdominal pain.
\nLaboratory tests, such as a complete blood count (CBC), electrolyte panel, and thyroid function tests, to rule out any underlying medical conditions that may contribute to the patient’s symptoms.
\nQuestions the nurse should ask with regard to the abdominal pain include:
\nWhen did the abdominal pain start?
\nCan you describe the pain (e.g., sharp, dull, cramping)?
\nDoes the pain radiate to any other areas?
\nAre there any factors that worsen or alleviate the pain?
\nHave you noticed any changes in the color, consistency, or frequency of your bowel movements?
\nHave you experienced any recent changes in your diet or lifestyle?
\nFrom the readings, subjective data, and objective data, the most probable cause of the abdominal pain is chronic constipation, which may be exacerbated by the patient’s use of laxatives and medications (Lamictal and Lexapro) that can contribute to constipation.
\nThe plan of care should include:
\nA thorough assessment of the patient’s symptoms, medical history, and medications.
\nEducation on lifestyle modifications, such as increasing dietary fiber and fluid intake, engaging in regular physical activity, and establishing a consistent bowel routine.
\nA review of the patient’s medications and possible adjustments to minimize constipation-related side effects.
\nMonitoring of the patient’s response to interventions and adjustments as needed.
\nInterventions that should be included in the plan of care for this patient are:
\nEncourage the patient to increase dietary fiber intake through fruits, vegetables, and whole grains.
\nRecommend increasing fluid intake, aiming for at least 8 cups of water per day.
\nEncourage regular physical activity, such as walking or swimming, to promote bowel motility.
\nEstablish a consistent bowel routine, including setting aside time each day for bowel movements and using relaxation techniques to reduce anxiety.
\nConsider a trial of over-the-counter stool softeners or fiber supplements, as needed.
\nCollaborate with the healthcare provider to review and adjust medications as necessary to minimize constipation-related side effects.
\nReference:
\nJarvis, C. (2016). Physical examination & health assessment (7th ed.). Philadelphia, PA: Saunders.<\/p>\n","protected":false},"excerpt":{"rendered":"
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