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Primary Admitting Diagnosis: Ulcerative Colitis 

Notes: Diagnosed with ulcerative colitis. Follow up with gastrointestinal physician as consulted. Complains of abdominal pain. Decreased appetite and multiple loose stools everyday for the past three days.

Family History: Patient’s grandmother diagnosed with ulcerative colitis at age thirty.

 

Pain Scale:

Pain Location – Abdomen

Frequency- Intermittent 

Type of Pain – Chronic 

Pain Goal – 0 No Pain 

Aggravating Factors – Movement, Coughing

Alleviating Factors – Rest, Medication, Immobility

Pain Scale Used – Wong Baker FACES 

Pain Characteristics – Aching 

 

Previous Nursing Notes 

 

1. Admitted to bed 6 in emergency room. Complaints of pain, see flowsheet. MD wishes to admit. Orders provided, will follow.

 

2. Admitted and transferred to pediatric unit per MD orders. Gastroenterology admitting. Vital signs stable. Transported via stretcher with parent to unit. Care released to Lovett, RN.

 

3. Admitted to unit per emergency room. Report received from Ross, RN. See flowsheet for details. Parent at bedside. no concerns at present time.

 

4. Mother pulled emergency call light. Xavier in bathroom doubled over in pain and can’t get off the toilet. Screaming “Something hurts really bad!.” Assisted Xavier back to bed, call light in reach, bed in low position, mother at bedside. Provider notified.

 

Vital Signs (Last three sets taken)

 

Blood Pressure – 102/58,  Heart Rate – 88, Respiratory Rate – 20, Oxygen Saturation – 100 on room air, temperature 98 oral

Blood pressure – 98/56, Heart Rate – 90, Respiratory Rate- 18, Oxygen Saturation- 100 on room air, temperature 98.2 oral

Blood Pressure – 106/60, Heart Rate – 88, Respiratory Rate- 22, Oxygen Saturation- 100 on room air, temperature 98.2 oral

 

Intake/Output

Intake – 60mL (ice chips)

Output- 200mL ( two stools and 200mL urine)

Balance= -140mL

 

MAR

codeine phosphate-acetaminophen 5 milliliters by mouth as needed

(Protocol/Note 12 mg codeine and 120 mg acetaminophen/5 mL As needed for pain)

 

Orders

Regular Diet

Frequent Vital Signs 

Frequent Intake and Output Assessment 

 

Question 

identify an ACTUAL priority problem; not necessary to use NANDA nursing diagnosis wording
type of problem identified
disease process or etiology contributing to identified problem
subjective and/or objective data specific to problem, as documented in EHR
at least one goal using SMART language (specific, measurable, attainable, realistic & timely)
at least 3 nursing independent and /or collaborative interventions appropriate to reach the chosen goal/outcome. Use the “Add Row” Tab to add extra spaces for interventions. Include at least:
an assessment intervention
a physical intervention that you would do
a patient education or teaching intervention
supportive rationale for choosing each nursing intervention
SCIENCE
HEALTH SCIENCE
NURSING
NUR 109

 

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