ShadowHealth Abdominal Pain Esther
Park A+Solutions
Nursing Diagnosis - ANS-Patient exhibits constipation related to deficient fiber and fluid
intake, as evidenced by abdominal discomfort and tenderness, defecation fewer than
two times per week, a distended abdomen, generalized fatigue, and a palpable
abdominal mass
Short term goal - ANS-To induce a bowel movement that relieves the patient's
constipation, resulting in patient reporting relief and diminished pain, within an
emergency department visit.
Interventions - ANS-1) Administer a mineral oil based enema with physicians order
2) Assess and fulfill patient needs for ambulating to the bathroom
3) Have patient ambulate the length of the hallway with patient care tech assistance
4) Provide patient with 500 ML of fluid and advise to drink over the next two hours
5) Tell patient to leave any outputs unflushed for examination
Data Collections - ANS-- Ask about pain rating, abdominal cramping, nausea, and
dizziness
- ask about patient outputs, presence of stool, and sense of constipation
- evaluate any store for amount and qualities
- evaluate for physical signs of pain and or cramping
- perform dehydration tests. Skin turgor, dry mouth, urine hat collection, and follow up as
necessary
chief complaint - ANS--reports abdominal pain
-reports difficulty with bowel movement
asked about orientation - ANS--oriented to own person
-oriented to place
-oriented to situation
-oriented to time
asked about onset, frequency, and duration of pain - ANS--reports discomfort for the
past 5 days
, -reports pain with gradual onset that worsened 2-3 days ago
asked about location of pain - ANS--reports pain in lower abdomen
-reports pain is not localized
asked about pain rating on scale - ANS--reports 6/10 pain
asked about characteristics of pain - ANS--describes pain a dull and cramping
-pain fluctuates in severity
asked about non-pharmacological relieving factors - ANS--denies taking pain
medication
-denies taking laxatives
asked about aggravating factors - ANS--reports pain is aggravated by eating
-aggravated by physical activity
asked about impact on daily life - ANS--recent difficulty participating in usual activities
-reports low energy
followed up on constipation - ANS--constipation most of last 5 days
-denies any attempt to treat constipation
asked about diarrhea - ANS-recent diarrhea
followed up about diarrhea - ANS--about 6 months ago
-sudden onset
-lasted one day
-loose and water
asked about substances in stool - ANS--denies mucus and blood in stool
asked about urination - ANS--recent, slight decrease in frequency of urination
-darker urine recently
-denies blood in urine
asked about fluid intake - ANS--decreased thirst
-decreased fluid intake for last few days
-typical fluid intake is 1-2 glasses water/day
-denies drinking caffeine
Park A+Solutions
Nursing Diagnosis - ANS-Patient exhibits constipation related to deficient fiber and fluid
intake, as evidenced by abdominal discomfort and tenderness, defecation fewer than
two times per week, a distended abdomen, generalized fatigue, and a palpable
abdominal mass
Short term goal - ANS-To induce a bowel movement that relieves the patient's
constipation, resulting in patient reporting relief and diminished pain, within an
emergency department visit.
Interventions - ANS-1) Administer a mineral oil based enema with physicians order
2) Assess and fulfill patient needs for ambulating to the bathroom
3) Have patient ambulate the length of the hallway with patient care tech assistance
4) Provide patient with 500 ML of fluid and advise to drink over the next two hours
5) Tell patient to leave any outputs unflushed for examination
Data Collections - ANS-- Ask about pain rating, abdominal cramping, nausea, and
dizziness
- ask about patient outputs, presence of stool, and sense of constipation
- evaluate any store for amount and qualities
- evaluate for physical signs of pain and or cramping
- perform dehydration tests. Skin turgor, dry mouth, urine hat collection, and follow up as
necessary
chief complaint - ANS--reports abdominal pain
-reports difficulty with bowel movement
asked about orientation - ANS--oriented to own person
-oriented to place
-oriented to situation
-oriented to time
asked about onset, frequency, and duration of pain - ANS--reports discomfort for the
past 5 days
, -reports pain with gradual onset that worsened 2-3 days ago
asked about location of pain - ANS--reports pain in lower abdomen
-reports pain is not localized
asked about pain rating on scale - ANS--reports 6/10 pain
asked about characteristics of pain - ANS--describes pain a dull and cramping
-pain fluctuates in severity
asked about non-pharmacological relieving factors - ANS--denies taking pain
medication
-denies taking laxatives
asked about aggravating factors - ANS--reports pain is aggravated by eating
-aggravated by physical activity
asked about impact on daily life - ANS--recent difficulty participating in usual activities
-reports low energy
followed up on constipation - ANS--constipation most of last 5 days
-denies any attempt to treat constipation
asked about diarrhea - ANS-recent diarrhea
followed up about diarrhea - ANS--about 6 months ago
-sudden onset
-lasted one day
-loose and water
asked about substances in stool - ANS--denies mucus and blood in stool
asked about urination - ANS--recent, slight decrease in frequency of urination
-darker urine recently
-denies blood in urine
asked about fluid intake - ANS--decreased thirst
-decreased fluid intake for last few days
-typical fluid intake is 1-2 glasses water/day
-denies drinking caffeine
