Kevin Valeri is a 64-year-old man who presents to the gastroenterologist’s office with constipation and abdominal bloating.
Subjective Data
Pain level is a 4/10 location = right lower abdomen
Retired Engineer
States he has been going to the bathroom with the help of laxatives, but not having regular movements
Appetite is decreased, some nausea
PMH: depression, anxiety, chronic constipation
Objective Data
Vital signs: T 37 degrees Centigrade, P 64, R 16, BP 124/58
Bowel sounds hypoactive in all four quadrants
Medications: Lamictal 200mg daily, Lexapro 10 mg daily
Weight = 210 lbs, last visit weight = 195
What other assessments should be included for this patient?
What questions should the nurse ask with regard to the abdominal pain?
From the readings, subjective data, and objective data, what is the most probable cause of the abdominal pain?
What should be included in the plan of care?
What interventions should be included in the plan of care for this patient?
APA FORMAT
REFERENCE REQUEIRED:
Jarvis, C. (2016). Physical examination & health assessment (7th ed.). Philadelphia, PA: Saunders.
Chapter 21: Abdomen
pp. 537–566 (Structure, Function, Subjective and Objective Data, Documentation and Critical Thinking)
Chapter 24: Male Genitourinary System
pp. 691–710 (Structure, Function, Subjective and Objective Data, Documentation and Critical Thinking)
Chapter 25: Anus, Rectum, and Prostate
pp. 721–731 (Structure, Function, Subjective and Objective Data, Documentation and Critical Thinking)
Chapter 26: Female Genitourinary System
pp. 737–763 (Structure, Function, Subjective and Objective Data, Documentation and Critical Thinking)
___________________
Other assessments that should be included for this patient are:
A thorough abdominal examination, including inspection, auscultation, percussion, and palpation.
A rectal examination to assess for any masses, fecal impaction, or other abnormalities.
A review of the patient’s medication list to identify any medications that may contribute to constipation or abdominal pain.
Laboratory tests, such as a complete blood count (CBC), electrolyte panel, and thyroid function tests, to rule out any underlying medical conditions that may contribute to the patient’s symptoms.
Questions the nurse should ask with regard to the abdominal pain include:
When did the abdominal pain start?
Can you describe the pain (e.g., sharp, dull, cramping)?
Does the pain radiate to any other areas?
Are there any factors that worsen or alleviate the pain?
Have you noticed any changes in the color, consistency, or frequency of your bowel movements?
Have you experienced any recent changes in your diet or lifestyle?
From the readings, subjective data, and objective data, the most probable cause of the abdominal pain is chronic constipation, which may be exacerbated by the patient’s use of laxatives and medications (Lamictal and Lexapro) that can contribute to constipation.
The plan of care should include:
A thorough assessment of the patient’s symptoms, medical history, and medications.
Education on lifestyle modifications, such as increasing dietary fiber and fluid intake, engaging in regular physical activity, and establishing a consistent bowel routine.
A review of the patient’s medications and possible adjustments to minimize constipation-related side effects.
Monitoring of the patient’s response to interventions and adjustments as needed.
Interventions that should be included in the plan of care for this patient are:
Encourage the patient to increase dietary fiber intake through fruits, vegetables, and whole grains.
Recommend increasing fluid intake, aiming for at least 8 cups of water per day.
Encourage regular physical activity, such as walking or swimming, to promote bowel motility.
Establish a consistent bowel routine, including setting aside time each day for bowel movements and using relaxation techniques to reduce anxiety.
Consider a trial of over-the-counter stool softeners or fiber supplements, as needed.
Collaborate with the healthcare provider to review and adjust medications as necessary to minimize constipation-related side effects.
Reference:
Jarvis, C. (2016). Physical examination & health assessment (7th ed.). Philadelphia, PA: Saunders.
