Ms. Dela Cruz, 25 years of age, presents to the triage nurse at the local emergency department complaining of severe generalized abdominal pain. She describes it as sharp and intermittent. She states, “Over the last four (4) days, I haven’t been able to have a bowel movement.” She states that she is able to drink liquids and urinates without difficulty. Bowel sounds are present in all four (4) quadrants, however, they are hypoactive (decreased or quiet peristalsis). Abdomen is distended and firm to touch. She states, “Two weeks ago I feel that my back hurts. My doctor gave me a prescription of Tylenol #3 and I have been taking it every 6 hours for pain.” She denies pain at the present time. Abdominal x-ray reveals a large amount of stool in her lower colon. All other diagnostic tests are unremarkable.

Comprehensive Medical Assisting: Administrative and Clinical Competencies (MindTap Course List)
6th Edition
ISBN:9781305964792
Author:Wilburta Q. Lindh, Carol D. Tamparo, Barbara M. Dahl, Julie Morris, Cindy Correa
Publisher:Wilburta Q. Lindh, Carol D. Tamparo, Barbara M. Dahl, Julie Morris, Cindy Correa
Chapter5: The Therapeutic Approach To The Patient With A Life-threatening Illness
Section: Chapter Questions
Problem 5.1CS
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 What is the nursing care plan of the following case scenario?

Ms. Dela Cruz, 25 years of age, presents to the triage nurse at the local emergency department complaining of severe generalized abdominal pain. She describes it as sharp and intermittent. She states, “Over the last four (4) days, I haven’t been able to have a bowel movement.” She states that she is able to drink liquids and urinates without difficulty. Bowel sounds are present in all four (4) quadrants, however, they are hypoactive (decreased or quiet peristalsis). Abdomen is distended and firm to touch. She states, “Two weeks ago I feel that my back hurts. My doctor gave me a prescription of Tylenol #3 and I have been taking it every 6 hours for pain.” She denies pain at the present time. Abdominal x-ray reveals a large amount of stool in her lower colon. All other diagnostic tests are unremarkable.

Assessment Diagnosis Goal/Object goal Planning  Intervention Rationale Evaluation

 

Objective data:

 

Subjective data:

     

Dependent:

 

Independent:

   
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