Patient Profile Activity Group 2 Patient Profile Activity

Patient Demographics Name: Charlotte P Sherman-Weber Age: 17 Gender: Female (born male) Height: 69 inches Weight 61.36kg Marital Status: Single Parental Status: Married parents

Patient Background

Patient Summary Admitting Diagnosis: Bowel Resection Primary Medical Diagnosis: Ulcerative Colitis Surgical Interventions Bowel Resection Diagnostic Test(s) Colonoscopy History or Present Health concern Diagnosed 2 years ago, symptoms became worse (abdominal pain, bloody stool) Past Health History Prolonged abdominal pain, blood in stool, diarrhea

Current Orders Diet Avoid alcohol, caffeine, carbonated drinks, dried peas, beans, legumes, and dried fruits. Patient should avoid foods high in fiber, refined sugars, and spicy foods. Rationale for Order recommended diet for those with ulcerative colitis Activity Bed rest Rationale for Order: avoid unnecessary pain or possible injury to colostomy insertion Mobility Limited mobility

Nursing Diagnosis Impaired mobility to perform or complete bathing/ hygiene activities related to pain as evident by a pain level of 7 on a 0-10 scale. Ackley (bathing self care deficit p. 677, 678)

Patient Outcomes Remain free of body odor and maintain intact skin State satisfaction with ability to use adaptive devices to bathe Use methods to bathe safely with minimal difficulty Bathe with assistance of caregiver as needed and report satisfaction, and dignity maintained during bathing experience Bathe with assistance of caregiver as needed without exhibiting defensive (aggressive) behaviors Ackley (bathing self care deficit p. 677, 678)

Nursing Interventions and Rationale Use of a prepackaged bath Rationale: avoid client exposure to pathogens, especially at site of incision, from contaminated bath basin, water source, and release of skin flora into bath water. Use client-centered bathing interventions: plan for client’s comfort and bathing preferences, show respect in communications, and use a gentle approach. Rationale: Focusing on the client rather than the task of bathing results in greater comfort and fewer defensive behaviors. Provide pain relief measure, such as ice packs, heat, and analgesics; move extremities slowly and carefully; and inform the client before movements associated with pain occur. Have the client wash painful areas, recognize indicators of pain, and apologize for any pain caused. Rationale: pain relief and client participation reduce discomfort, preserve dignity, and give a sense of control. Ackley (bathing self care deficit p. 677, 678)

Day # 2 Today you are assigned to care for Charlotte again and you note during your assessment that her surgical incision on her upper abdomen is red, irritated has opened from when you assessed it yesterday. You call the doctor and he orders you to pack it with a dry to dry dressing. What would her priority nursing diagnosis be today? Write a care plan based on the priority diagnosis.