Amber Johnson
Clinical Paperwork
Patient: Age- 85
Allergies- NKA Sex- Male
Critical Thinking Summary
Patient Diagnosis: Lower left quadrant and abdominal pain.
Medical Diagnosis: Diverticulitis
Pathophysiology: Diverticulitis occurs when the diverticula become inflamed or
microperforated. Patients generally have increased muscular thickness and increased
intraluminal pressure. A diet with insufficient fiber. It is caused when stool and bacteria are
retained in the diverticular out pouches, leading to formation of a hard mass called fecalith.
Symptoms: Generally asymptomatic, but report cramping and abdominal pain in the lower left
quadrant.
Patient’s Symptoms: Abdominal pain.
Nutritional Assessment: Height- 170.18 cm
Weight- 71.4 kg
Ideal Body
Weight- 65.3kgs
Well Nourished- Pt. does appear to be well nourished for his age, based
on characteristics.
Psychosocial Stage Of Development: Developmental Stage- Ego integrity vs. despair “Did I have
a meaningful life?”. Pt. appears to have met the necessary accomplishments, however seems
to be leaning more towards despair based on his appearance.
Illness Affecting Patient’s
Ability To Meet Accomplishments- Pt. appears to be unsocial and unable to cope with feelings
of illness.
Physician Prescribed Medications And Interventions
1. AmLODIPine (Norvasc)- Calcium channel blocker used for hypertension and angina.
Adverse Reactions- Swelling, Pounding Heart, and Chest Pain. Check blood pressure
immediately before administration. Order- 5mg= 1 tab PO daily.
2. Amplicillian-Sulbactam (Unasyn)- Penicillin antibiotic for bacteria infection. Adverse
Reactions- Allergic Reaction, Diarrhea, Fever, and Chills. Do not use if pt. is allergic to
penicillin. Order- 1.5g= 5ml IVPB q6.
3. Docusate-Senna (Doc-Q-Lax)- Stool softener used for constipation. Adverse ReactionsRectal Bleeding, Stomach Pain, Nausea, and Vomiting. Do not take with mineral oil.
Order- 2tab PO daily.
4. Escitalopram (Lexapro)- Antidepressant used for SSRI. Adverse Reactions- Allergic
Reaction, Rash, Hives, Swelling, Difficulty Breathing. Do not give to a child under the age
of 12. Order- 5mg= ½ tab PO daily.
5. Finasteride (Propecia)- Prevents testosterone for BPH enlarged prostate. Adverse
Reactions- Breast Lumps, Pain, and Discharge. Do not crush or give to a woman or child.
Order- 5mg= 1 tab PO daily.
6. Pantoprazole (Protonix)- Proton Pump Inhibitor used to decrease the amount of acid in
the stomach. Adverse Reactions- Abdominal Pain, Diarrhea, Headache, Nausea, and
Rash. Do not crush. Order- 40mg= 1tab PO daily.
7. Polyethylene Glycol 3350 (Miralax)- Laxative used for constipation. Adverse ReactionsSevere Bleeding and Diarrhea. Dissolve 1 packet of miralax in 8oz of water, juice, soda,
or coffee. Order- 17g= 1 packet PO daily.
8. Tamsulosin (Flomax)- Alpha Adrenergic Blocker used to relax muscles in the prostate.
Adverse Reactions- Chest Pain, Fever, and Chills. Do not crush, chew, or open. Order0.4mg= 1 cap PO daily.
9. Acetaminophen hydrocodone (Norco)- Opioid given for pain. Adverse ReactionsDecrease in Respirations and Sever Skin Reaction. Maximum dose 4000mg/24 hr.
Order- 1 tab PO q4h PRN.
10. Hydralazine (Apresoline)- Used for hypertension. Adverse Reactions- Allergic Reaction,
Tachycardia, Pale Skin, and Bruising. Check blood pressure before administration, after
administration check blood pressure and heart rate every 15, 30, and 60 minutes.
Order- 10mg= 0.5 ml IVP q2h PRN.
11. Onadansetron (Zofran)- Used for nausea and vomiting. Adverse Reactions- Allergic
Reaction, Uneven Heart Rate, and Light Headedness. Don’t use if history of lone QT
syndrome. Order- 4mg= 2ml IVP q8h PRN.
12. Promethazine (Adgan)- Used for nausea and vomiting. Adverse Reactions- Allergic
Reaction, Twitching, and Blurred Vision. Fall Risk Medication dilute with normal saline.
Order- 6.25mg= 0.25 ml IVP q6h PRN, 1000ml 75ml/hr.
Analysis Of Diagnostic Tests
1. CT abdomen and Pelvis w/o contrast: Given for flank pain, Findings suggesting sigmoid
diverticulitis.
2. Glucose: 139, high due to drug amlodipine, Norvasc, can increase glucose levels.
3. Calcium:8.2, low, calcium is not readily absorbed therefore patients increase vitamin D
intake.
4. Hgb: 11.6, low, may indicate bleeding in the GI tract, also suggests low oxygen carrying
capacity due to low RBCs.
5. Hct: 34.3, low, may indicate bleeding in the GI tract.
6. RBC: 4.13, low, may indicate bleeding in the GI tract.
7. Platelet: 117, low, may indicate bleeding in the GI tract, decreased ability to clot blood
as well.
Nursing Diagnosis/Objectives/Interventions
Diagnosis: Constipation related to irregular defecation habits and calcium channel blockers as
evidence by not defecating.
Defining Characteristics: Taking Norvasc, has not had a bowel movement in 5 days even with
laxatives.
Objective/Patient Outcome: State relief from discomfort of constipation.
Nursing Interventions: Review client’s medications/ consult to change. Palpate for abdominal
distention, percuss for dullness, and auscultate bowel sounds. Encourage fiber intake of
20g/day for adults.
Diagnosis: Imbalanced nutrition related to loss of appetite as evidence by not eating meals
well, patient consuming less than 25% of meals.
Defining Characteristics: Eating less than 25% of meals, no urge of hunger.
Objective/Patient Outcome: Identify nutritional requirements, and consume adequate
nutrition.
Nursing Interventions: Weigh client daily. Watch labs, note serum albumin, hct, and
electrolyte balances. Monitor food intake and ability to eat.
Complications: If patients condition were to worsen what would most likely be the reasonBecause patient is not very active and not eating much, he is not getting enough vitamins and
fiber as needed. I would watch his labs and notice any symptoms of insufficient vitamins and
minerals. It this is appearing to happen I would consult with the physician about maybe
needing supplements.