Question

Using the nursing process: Prepare a care plan.

S.T. is a 40 year-old female weighing 120 lbs and lives with her family in a single home. Today she is admitted complaining of left-sided severe abdominal pain which is relieved at the hospital with medications. She reports, “My pain level is much better! 2/10 now. It was 10/10.” S.T. states she has lost weight over the last two months. She was 160 lbs. S.T. says she makes herself eat but just isn’t hungry. Complains of being “tired all the time” and feels nauseous when she smells food. The morning tray is at the bedside an ¼ is eaten. Her stools are dark and soft. Urine output is 1500 mL/day clear yellow. Her vital signs are Heart Rate (HR) 88(high) regular Respiratory Rate (RR) 18 Blood pressure (Bp) 110/86 Temperature 99.6F(high) Oxygen saturation 99% Her family is at the bedside (husband, daughter (13) and son (11). They appear concerned but conversational.

Answer 1

Patient name ST

care plan by Sophie

Date of initiation 12-08- 2020

Assessment

Complaints of abdominal pain

history of significant weight loss Present

Lethargy present

Loss of appetite present

loss of appetite present

Heart rate 88 High

Febrile temperature 99.6 Fahrenheit

Provisional diagnosis

Malignancy

Tuberculosis TB

Inflammatory bowel disease

Outcome

Patient vitals are stable. There is no imminent threat to life.

Interventions

Continuing vital monitoring

Adequate Analgesics

rationale

Vitals monitoring is of paramount importance and because it could be a presentation of acute abdomen or a serious illness which needs continuous vital monitoring by the healthcare worker.

Adequate Analgesics makes the patient comfortable so that further evaluation can be done by the concerned team and When it management of the problem can be started at the earliest

when it management of the problem can be started at the earliest

Evaluation

on reassessment the pain score of the patient how far and from 10/10 to 2/10