Surname 1

Student’s Name

Professor’s Name

Course

Date

Patient’s Biographic Data

The patients’ initials are C.L, and she is 67 years old. She was born on 1 May 1955and

her gender is female. Currently, she is on retirement, therefore not working but enjoys working

on farms. C.L is deceased. Asian American is her ethnicity. Her physical address is a care

nursing home resident. She currently does not have a phone number. Her primary language is

English. C.L is a mother of five: two daughters and three sons. The eldest son holds her power of

attorney.

Health history

Source: the son was requested to fill in a health history questionnaire. He also brought

some signed documents from her former doctors. This provided us with proper knowledge of her

condition. In addition to these, we contacted some of the hospitals she had been treated in to get

some more intel on her health condition.

Reason for seeking care: C.L had inflammatory bowel disorder. The patient was brought

after her son found her drowsy and decreased responsiveness. He reports that she had had

abdominal pain for weeks.

History of present illness: Since the patient started using heroin, she has had the

condition. it is now eight years since she got her first case of an altered mental status
 Surname 2

Past health: C.L has lived a healthy life before her addiction to the hard drug. Despite her

family history of diabetes mellitus, she did not have any signs or symptoms of suffering from it.

Her sons say she had a very healthy lifestyle. This kept her from suffering the disease. However,

when she started smoking, it could no longer stay away from her.

Family history: According to the son, her family has a history of diabetes mellitus. He

claims eight out of every ten family members suffer from it. There are no allergies, heart

diseases, cancers or high blood pressure cases in the family

Review of systems

General or constitutional review of systems: C.L reports several instances of fever and

denies chills. The patient denies tender or swollen lymph nodes. Psychiatric: memory loss, stress,

and anxiety are present. Denies depression. Fatigue exhibits Abdominal pain. Skin: There are no

rashes on her skin. No diaphoresis. Swollen, tender, and red on the legs. Hair: normal color, no

hair loss. Head: instances of slight headaches. Eyes: no rhinorrhea or conjunctivitis. Ears: wears

hearing aid device Nose: pain from time to time, no running nose Mouth: complains of non-

healing sores in the mouth has a dry mouth. Throat has congestion but no soar throat, denies

trouble or pain swallowing—neck: no swollen glands.

Breast: Breast pain, soreness, lumps, or discharge. Axilla: no soreness or lumps.

Respiratory: dry coughs and shortness of breath. Cardiovascular experiences chest pain when

coughing. Peripheral vascular: no pain, some numbness, tingling, swelling, and weakness in the

legs with pain Loss of hair on the legs. Gastrointestinal: denies heartburn or indigestion, nausea,

and vomiting. Low appetite complaints, Persistent diarrhea with bloodstains. Urinary; no pain,

normal urine color, no presence of blood. Female Genital: no complaints. Sexual: N/A.
 Surname 3

Musculoskeletal: complaints of muscle cramps. Neurologic: no history of stroke, no dysphagia.

The patient has no speech problems Haematology: shortness of breath, dizziness. Endocrine:

weight fluctuations, mood swings

Functional assessment

Education- C.L has little formal education. She received nonformal education from her

elders and parents. This form of education is known as apprenticeship. The formal education she

received is adult education. She said she was very passionate about education and particularly

interested in science. She says her parents were not very supportive of girl child education.

Financial status: she has a pension and receives a financial boost from her children once in a

while. She says the money is enough to sustain her lifestyle. Activity or exercise: the patient says

she rarely does any leisure activities and never exercises (Stelfox et al. 1390). Sleep and rest. C.L

says she sleeps very well, uninterrupted. She spends most of her time resting. Nutrition: since she

is a nursing home resident, she has a meal schedule. The home offers a balanced diet, but C.L

says she hates eating greens and plants proteins. Spiritual resource. She reads spiritual books, not

the bible. She also attends church once in a while

Interpersonal relationships: the patient expresses that she is very outgoing and has several

friends she likes hanging out with. She also says she is close to all her children and speaks to

them regularly. Since she was a widow, C.L has never tried to date again or seen anyone. She

prefers to stay without a partner because she loves her husband very much and misses him a lot

(Baumgart et al. 1627). She feels like having someone else will not be a good idea. Coping and

stress management. The patient says she took to drugs to minimize stress. When she cannot

afford the heroin, she speaks to close friends until she breaks down. Once in a while, she says

she drinks alcohol to manage her stress.

 Surname 4

Personal habits: C.L admitted to heroin usage. She also says she does alcohol, however

not so often. She used to do tobacco smoking. She loves coffee and tea. She is not annoyed by

people criticizing her drinking. She sometimes feels guilty about her drinking but has never had a

drink to get over a hungover in the morning. She does not feel the need to reduce her alcohol

intake. Environmental hazards: the nursing home has done some proofing around the rooms and

environment to keep them from harm.

Physical assessment

Subjective data or complaints: The patient complains of stubbing pain in the legs. Neurological

has trouble moving the legs at times, especially when it is cold. Cardiovascular: the first and the

second heart sound were okay (Patiraki et al. 88). Respiratory: her breathing sounds unlabored,

equal bilaterally, and with good effort. G.I.: has a distended abdomen GU: blood in the stool.

Musculoskeletal. Integumentary: has swollen legs.

Pathophysiology

The pathogenesis of IBD is inclusive of ulcerative colitis and Crohn’s disease. Pathogenic

features like environmental changes, immune response dysregulation, abnormal gut microbiota,

and gene variants are involved in the process. The precise source of IBD is unidentified.

Nevertheless, IBD is the outcome of a flawed immunity. An accurately working immune system

bouts foreign bacteria and viruses to guard the body (CDC). In IBD, the defense system responds

erroneously to environmental triggers, causing swelling of the digestive tract. There similarly

seems to be a genetic element; a person with a family history of IBD is likely to mature this

unfortunate immune response.

 Surname 5

Diagnostic Procedures & Laboratory Results.

Diagnosis Diagnostic Lab test reports Analysis of results

procedure
Inflammatory Bowel colonoscopy Abdominal pains. Bleeding along the gut
disease Diarrhea blood in stool
Inflammatory Bowel Stool studies Presence of blood in the Bleeding along the gut
disease stool
Iron-deficiency ABG Shortness of breath, Low Ph, PCO2,
anemia (IDA) dizziness, and weakness Normal PO2, HCO3
Iron-deficiency CBC Shortness of breath, Low hemoglobin, ribs,
anemia (IDA) dizziness, and weakness Hematocrits, MPV, lymphocyte
% lymphocyte count, chloride
serum
HIGH WBR, RDW, glucose
serum, monocytes count,
monocytes %, eosinophil count,
CO2serum, bun serum
Normal MCV and MCH, MCHC,
platelets, neutron count, neutron
%,

Cellulitis edema on bilateral arms This is a case of bacterial

and abscess on the right infection
side of the lower leg

Medications

Medication (as Specific Reason for Side Effects, Patient and Family
ordered by provider) Taking Them Teaching
– Classification –
How does the
medication work
(chemical action)?
Aspirin 81 mg P.O. To reduce fever Stomach irritation Take the aspirin
Daily Classification: when fever or
Antiplatelet Chemical headaches occur
Action: Blocks
Thromboxane A2 to
prevent platelet
aggregation.
mesalamine (anti- To treat inflammation May cause nausea Inform your doctor
 Surname 6

inflammatory) IV, and vomiting that you are taking

methylprednisolone the drug before
IV having any lab tests
Action: It stops the
production of a Attend every medical
substance that may appointment
bring about
inflammation.
Psyllium powder To regulate blood Cramps, gas Ensure not to miss a
Action: absorbing sugar levels single dose of this
excess water as it is drug
stimulating usual
bowel elimination
Cefazolin Blood count increase Swelling of injection
Action: inhibits the site
synthesis of bacterial
cell wall
Ferrous Sulfate Increase iron in the Dark green stool The patient should
Action: works by blood Loss of appetite refrain from alcohol
combining iron with consumption.
globin chains and
porphyrin to produce
hemoglobin

Intravenous fluid: N/A

Collaboration interdisciplinary team

While treating C.L, I interacted with several professionals, including surgeons, registrars,

pharmacists, dietitians, Consultant Gastroenterologists, IBD Nurse Specialists, and

Psychologists. They all provided advice in their field of expertise. Advising on the foods the

patient should take, they spoke to the patient to assess her conditions and so much more. They

were all very helpful. The nursing attendant ensured the patient took her medications as

prescribed and offered her company whenever she requested. She reported to me every day in

person, and I ascertained by asking the patient.,

Interventions
 Surname 7

Nursing Expected Nursing Interventions & Evaluation

Diagnoses Outcomes/Goals Rationales
Inflammatory Reduced abdominal Providing medication- to Carrying out stool
bowel disease pains help cure the patient tests to ascertain the
Drinking 8-10 glasses of absence of blood in
water- to increase fluids stool
in the body
If a therapeutic effect is
not achieved, then
surgery will be
considered- to get rid of
the problem completely.
Eat high protein fiber-
enhance proper digestion.
Increase intake of
proteins from fish-
increase the healing
process of wounds.

Iron-deficiency Normal blood count Improved diet habits Blood count checks
anemia increases the rate of every often.
healing.

cellulitis Stop drug use cefazolin, Drug test

Healing of the wounds dressing change on the
lower leg,
methadone for drug
abuse

Discharge planning

C.L should take the prescribed medication religiously. She should also live in a clean

environment away from physical harm or mental torture. Her diet should be inclusive of foods

rich in iron, such as liver (nursing center). She should also take foods rich in aminal protein and

fiberIf the need arises, she should keep in touch with her dietitian and psychologist. C.L. should

come for a check-up after two weeks to monitor her progress.

 Surname 8

Work cited

Baumgart, Daniel C, and Simon R Carding. “Inflammatory Bowel Disease: Cause and

Immunobiology.” The Lancet, vol. 369, no. 9573, 2007, pp. 1627–1640.,

https://doi.org/10.1016/s0140-6736(07)60750-8.

Patiraki, Elisabeth, et al. “Nursing Care Plans Based on Nanda, Nursing Interventions

Classification, and Nursing Outcomes Classification: The Investigation of the

Effectiveness of an Educational Intervention in Greece.” International Journal of Nursing

Knowledge, vol. 28, no. 2, 2015, pp. 88–93., https://doi.org/10.1111/2047-3095.12120.

Stelfox, Henry T., et al. “Assessment of the Safety of Discharging Select Patients Directly Home

from the Intensive Care Unit.” JAMA Internal Medicine, vol. 178, no. 10, 2018, p. 1390.,

https://doi.org/10.1001/jamainternmed.2018.3675.