1. Patient Profile Activity
Group 2
Patient Profile Activity

2. 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

3. Patient Background

4. 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

5. 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

6. 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)

7. 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)

8. 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)

9. 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.