J.D.

J.D.

1. Crohn's Disease

   • g-tube (for emergencies)
   • History of 2 major bowel ressections
   • Central arterial line
     • 1mL- 70% ethanoll-locked (removed prior to flushing, and inserted after TPN and cares)
   • TPN only source of nutrition= high risk for catheter related bloodstream infection
   • no other medications for crohn's or other conditions
   • Risk for nutrition imbalance, less than body requirements r/t crohn's dz aeb need for TPN ; hx of bowel ressections
     • Goal- Patient will maintain adequate nutrition during HHC admission through discharge aeb appropriate screening tool and normal weight
     • assess patient with utilization of nutrition screening tool
     • teach patient to self-administer TPN
     • assess patient compliance with TPN and iron dextran
     • assess patients output (urine and stool)
     • monitor lab results as available
     • Evaluation: nutrition screenings will be normal and appropriate, weight will be normal for age/height, patient will be compliant with TPN and iron dextran, albumin and other nutritional labs will show normal results, urine and stool will be appropriate color/consistency/frequency
   • Abdominal pain/cramping, weight loss, anemia, diarrhea, bloating, hx of bowel obstruction
   • risk for deficient fluid volume r/t crohn's aeb diarrhea
     • Goal- maintain adequate fluid volumes/hydration during admission and through til discharge
     • encourage adequate fluid intake
     • educate patient to take daily weights and report sudden changes
     • assess vitals
     • assess skin turgor and mucous membranes
     • monitor labs as available
     • evaluate capillary refill
   • Chronic pain r/t crohn's dz aeb patient report of pain
     • Patient will have pain well controlled at acceptable level of 2 or lower through admission to discharge
     • encourage patient to stay NPO as ordered
     • administer tylenol as needed
     • teach and encourage patient use of yoga, guided imagery, and other nonpharmacological pain relief
     • Evaluation: numeric scale will be used and patient will report pain at level of 0-2, with decreased frequency and report better pain control
     • regularly assess pain
   • risk for ineffective coping r/t chronic nature of crohn's aeb preoccupation with physical self and anxiety
     • Goal- patient will learn and utilize effective coping strategies through to discharge
     • encourage patient to discuss /verbalize feelings
     • assess patients understanding of disease
     • assess patients previous coping strategies
     • assess patients support system
     • refer patient to support group and mental health if necessary
     • Evaluation: patient will discuss feelings about chronic illness, will report more positive outlook on condition and life with the condition. Evaluation will be made of the patients affect, hygiene, and interest in activities in life.
     • determine individual stressors
   • Risk for powerlessness r/t chronic condition aeb risk factors of feelings of loss of control of self
     • Goal- patient will verbalize control over reasonable areas of care and take initiative to excise power and control over care through admission
     • identify patients knowledge and perception of condition and treatment plan
     • identify client's locus of control (internal vs external)
     • enxourage client to express feelings
     • allowe opportunities and teach patient ways to promote independence and give back some control
     • express hope for client
     • Evaluation: patient will discuss feelings and take initiative in care. Patient will verbalize increasing feelings of power and control over self and care.

2. Iron-deficient anemia; r/t crohn's disease

   • Iron Dextran weekly (dose unknown)
   • Vitamin B complex (OTC dose unknown) to assist in energy improvement
   • Weak, tired, low energy, dizzy, brittle nails, hair loss

3. Immune deficiency

   • risk for infection r/t central arterial catheter (TPN) and foley catheter) aeb inadequate immune globulins and easy infections
     • Utilize Triple betadine cleaning for sterile dressing change for central line cares as ordered
     • proper hand hygiene (patient, visitors, staff)
     • monitor central line, old central line wound, stoma site, urine, and other areas for potential s/s of infection
     • utilize sterile technique for central line dressing change
     • teach patient proper techniques for self administration of TPN
     • Monitor labs (when available)
     • Goal- Patient will remain free from infection during HHC admission through discharge
     • Evaluation: labs and wounds will be observed and monitored and be clear of redness, warmth, edema, pain, odor. WBC count will be within normal range. nurse will observe patient completing proper hand hygiene.
   • Alcohol-locked central line
   • TPN contains higher concentration of Vitamin c and zinc
   • frequent infections, slow wound healing, low/inadequate immunoglublins

4. Allergies: Heparin

5. No available labs or other diagnostic testing

6. otherwise healthy!