NURSING Care Plan History of Crohn’s
disease
NURSING Care Plan History of Crohn’s disease
KARI (on phone): This is Kari the nurse from the Emergency
Department. I’m calling to give you a transfer report on Ms. Janet
Lieberman. Janet is a 36-year-old woman who came because she
felt weak and dizzy. She has a history of Crohn’s disease with
intermittent gastritis and six months ago she had surgery and an
ileostomy. Traces of serosanguineous effluent were present in her
ostomy bag upon arrival. Her Blood type is A-. She is typed and
cross-matched for two units of packed RBCs, so please administer
as soon as they are available. She started on Infliximab IV six
months ago and the last dose was given seven weeks ago. Her
vital signs were temperature 98.8, pulse 114, respiration 22, blood
pressure 100/60, and oxygen saturation 95%. Her hemoglobin is
seven milligrams per deciliter and her hematocrit is 21%. She has
an IV of 0.9% sodium chloride 1000- milliliters infusing at 150-
milliliters per hour, and has 700-milliliters remaining in the bag.
We started an IV while she was in ED. Her skin has been pale,
warm, and dry to the touch. She voided 500-milliliters at 1500 in
the ED. A hemoccult of her stool was sent to the lab. Esther: Were
the coagulation tests within normal range? KARI: Yes, her pro time
is 12.2, her PT is 21 seconds, and her INR is 0.7. Esther: Okay, thanks
for the report. KARI: You’re welcome. I’ll bring her up to your unit in
a few minutes. Esther: Thanks. KARI: Hi Esther, this is Janet
Lieberman. Esther: Hi Ms. Lieberman, my name’s Esther. I’ll be
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