T.H., a 57-year-old stockbroker, has come to the gastroenterologist for treatment of recurrent mild to severe cramping in his abdomen and blood-streaked stool.
T.H., a 57-year-old stockbroker, has come to the gastroenterologist for treatment of recurrent mild to severe cramping in his abdomen and blood-streaked stool. You are the registered nurse doing his initial workup. Your findings include a mildly obese man who demonstrates moderate guarding of his abdomen with both direct and rebound tenderness, especially in the left lower quadrant (LLQ). His vital signs are 168/98, 110, 24, 100.4 F
(38
∘
C); he is slightly diaphoretic. T.H. reports that he has periodic constipation. He has had previous episodes of abdominal cramping, but this time the pain is getting worse. Past medical history reveals that T.H. has a “sedentary job with lots of emotional moments,” he has smoked a pack of cigarettes a day for 30 years, and he had “two or three mixed drinks in the evening” until 2 month 5 ago. He states, “I haven’t had anything to drink in 2 months.” He denies having regular exerciset “just no time.” His diet consists mostly of “white bread, meat, potatoes, and ice cream with fruit and nuts over it,” He denies having a history of cardiac or pulmonary problems and has no personal history of cancer, although his father and older brother died of colon cancer. He takes no medications and denies the use of any other drugs or herbal products. Skeleton Diagram Reason for seeking help: Analyze and Categorize the Data Reason for seeking healthcare: Priority assessment: REASON FOR SEEKING HEALTH CARE: Problem/Nursing #1: Goal/Qutcome: Interventions: Patient Responses: Evaluation: Problem: Nursing Dlagnosis #2: Goal/Outcome: Nursing Interventions: Patient Responses: Evaluation: Problem/Nursing Diagnosis # 3: Goal/Outcome: Nursing Interventions: Patient Responses: Evaluation:
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