J.P. is a 50-year-old man who presents to the gastroenterologist…

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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

Question 1

What other assessments should be included for this patient?

Question 2

What questions should the nurse ask with regard to the abdominal pain?

Question 3

From the readings, subjective data, and objective data, what is the most probable cause of the abdominal pain?

Question 4

Develop a problems list from the subjective and objective findings.

Question 5

What should be included in the plan of care?

Question 6

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