1 Crohn s disease

1 Adult Patient Assessment Sheet • Student's Name: Danah Ibrahim Zakri • ID: 445006471 • Course name: Adult 1 • Date of assessment: 27/10/2024 * Bio-clinical-sociodemographic data • Patient's initials: BMI • Department: Surgical department • Nationality: Saudi • Age: 20 • Religion: Muslim • Gender: Male • Marital status: Single • Level of education: university • Occupation: Cybersecurity unversity student • Date of admission: 23/10/2024 • Diagnosis: Crohn's Disease flare-up • Name of operation: None • Date of operation: None • Post-operative days: None 1. Health history • Reason for Hospitalization: Crohn's disease flare-up. • Chief/present Complain during the day of examination: Right lower abdominal pain, colicky in nature, decreased oral intake for 2 days prior to admission. o Onset: Gradual o Duration: 4 days.

2 o Aggravating factors: Eating certain foods, such as fatty foods, spicy foods, and high- fiber foods Emotional or physical stress o Alleviating factors: Rest and avoiding strenuous activities Drinking adequate fluids to prevent dehydration o Associated manifestations: Chronic diarrhea and cramping Fatigue, weight loss and Reduced oral intake 1. Health History (before hospitalization) Item Please circle If (yes) Specify Past history Previous hospitalization No Yes Due to intra-abdominal and abdominal wall collection treated with IV and oral antibiotics. Associated diseases No Yes Crohn's Disease (perianal, entero-enteric, entero- colic fistulizing) Previous surgery No Yes Allergies No Yes Previous blood transfusion No Yes Type ____Amount ____Date ____ Family history Cancer No Yes Hypertension No Yes Father, diagnosed 8 years ago Diabetes Mellitus No Yes Kidney disease No Yes Asthma No Yes Heart disease No Yes Liver disease No Yes Others No Yes Lifestyle/health patterns/habits Medication: - Prescribed - Over The Counter (OTC) No No Yes Yes Smoking: - Non-Smoker - Smoker - Passive smoker - Quitter No No No No Yes Yes Yes Yes Type_________ No per day: ____ No of years: ____ Alcohol intake: No Yes.

3 Nutrition: - Frequency ( 3 meals/day) - Likes: Rice, chicken; Dislikes: high-fiber foods - Amount of fluid intake 2 L/day Elimination - Bowel Frequency:1-2 times/day ( - Urinary frequency: 6-8 times/day Sleep - Sleep hours: Day: 0 hours; Night: 6-8 hours - Altered sleep: Yes (interrupted sleep due to abdominal discomfort) Level of activity: - Independent ( yes ) - Partial independent ( no ) - Dependent ( no ) - Specify: none Others: None 2. Physical examination (currently at the day of assessment) General Appearance • Consciousness: Alert, oriented to person, place, and time , No Any signs of confusion or altered mental status • Posture: Erect, no scoliosis, kyphosis, lordosis, or unable to assess due to patient condition • Grooming: Well-groomed, with good condition of hair, clothing. • Hygiene: Clean, not unwashed or body odor present • Weight: 46.5 kg • BMI: 19.11 (Normal weight) • Gait: Normal • Vital Signs: • Temperature: 36.2 • Pulse: o Rate: 70 BPM o Rhythm: Regular o Force/Intensity: Strong • Respiration: o Rate: 16 breath per cycles o Rhythm: Regular o Depth: Normal • Blood Pressure: o Value: 95/61 o Site: Right arm • Pain: o Site: Right lower abdomen o Severity (VAS/NAS): 6/10 o Radiation: No o Increasing Factors: Touch and movement o Decreasing Factors: Rest and medication.

4 Face Others None No Yes Mouth Lips Lips are smooth, moist, and free from cracks; healthy pink color. Normal Abnormal Mucus membrane Clean, intact, and free from cavities. Normal Abnormal Teeth Fresh and free from foul odors. Intact Lost Odor Fresh and free from foul odors. Absent Present Tongue Pink, moist, and free from lesions or coating Normal Abnormal Others None No Yes Item Describe the findings Your interpretation Head Shape Normocephalic, symmetrical Normal Abnormal Amount and distribution of hair Distributed across scalp, no patches or brittleness Normal Abnormal Presence of lice No lice No Yes Presence of dandruff No dandruff No Yes Scalp Clean, intact, healthy, no lesions/redness Intact Not intact Others None No Yes Face Color Normal, even tone, no discoloration/redness Healthy Unhealthy Eye Vision Clear, no blurriness Normal Impaired Sclera Color White Normal Abnormal Eye pupil re light action to Pupils Equally Round, Reactive to light, and Accomodation Normal Abnormal Others None No Yes Ear Hearing Normal, hears soft sounds without difficulty Normal Impaired Others None No Yes Nose Patency Both nostrils patent Patent Not-patent Position septum of nasal Midline Normal Abnormal.

5 Item Describe the findings Your interpretation Neck Jugular veins No visible pulsations or swelling; not distended. Flat Congested Range of motion (ROM) Full range of motion; no discomfort during movement. Free Limited Others None No Yes anterior & posterior chest Inspection - Shape of chest wall Chest symmetrical with no deformities; both sides expanding equally. Normal Abnormal - Chest movements Chest movements are equal. Equal Unequal - Use of accessory muscles No use of accessory muscles for breathing. No Yes - Spinal Alignment Spinal alignment is straight and well-aligned, with no noticeable curvatures. - Others None No Yes Palpation - Chest expansion Both sides expand equally. Equal Unequal - Tenderness No tenderness upon palpation. No Yes - Lumps No lumps or masses detected. No Yes - Others None No Yes Percussion - Percussion sound Loud, low-pitched sound that is hollow and booming. Resonant Abnormal Auscultation - Air entry Equal air entry in both sides. Bil-equal diminished - Breath sounds Normal (vesicular and bronchial) Normal Abnormal - Heart sound Normal, no murmurs Normal Abnormal - Apical pulse Rate 78, regular rhythm, strong intensity - Others No Cough, Chest pain, Orthopnea, Paroxysmal nocturnal dyspnea or Dyspnea No Yes.

6 Describe the findings Abdomen Inspection - Shape Flat, no distension, ascites, hernia, or ostomy Normal Abnormal - Skin integrity Intact, no scars or rashes Normal Abnormal Auscultation - Bowel sounds Present Palpation - Abdominal palpation Soft Tenderness in RLQ No masses, splenomegaly, or hepatomegaly. Normal Abnormal - Nutritional pattern Nausea, NPO; regular diet prior to admission Oral Others - Bowel elimination pattern 1x/day prior to admission, formed brown stool. Currently NPO Normal Abnormal - Others Pain present, no vomiting or anorexia No Yes Urinary System Urinary elimination pattern Frequency /day The urinary elimination pattern showed an average frequency of urination per day and normal color and amount without dysuria, polyuria, anuria, or urgency noted. Normal Abnormal Upper & Lower Extremities Skin color Pink color, no cyanosis, pale or yellowish Normal Abnormal Skin integrity Intact, no Scars or Lesion Normal Abnormal Skin temp. Warm Normal Abnormal Skin turgor Elastic, no Non-elastic or Dry Normal Abnormal Sensation Normal, no numbness/paresthesia Normal Abnormal Varicose veins None Absent Present Edema None Absent Present Nails color Healthy in color Normal Abnormal Nails shape Healthy in shape, without clubbing or brittleness Normal Abnormal Capillary refill Capillary refill time was less than 3 seconds Normal Abnormal Joints oint movement was free with no swelling or deformities Normal Abnormal Others No amputation or other deformities Absent Present.

7 Describe the findings LN Cervical Axillary Femoral Cervical, axillary, and femoral lymph nodes were non-palpable and not tender. Normal Abnormal Peripheral Pulse Temporal Present and regular Normal Abnormal Carotid Present and regular Normal Abnormal Brachial Present and regular Normal Abnormal Radial Present and regular Normal Abnormal Femoral Present and regular Normal Abnormal Popliteal Present and regular Normal Abnormal Posterior Tibial Present and regular Normal Abnormal Dorsalis pedis Present and regular Normal Abnormal Back Presence of pressure ulcers NO pressure ulcer Present Absent Others None Normal Abnormal i ti es.

8 3. Laboratory & Diagnostic findings: a. Abnormal laboratory studies Name of test Value (unit) Interpretation C-reactive Protein (CRP) Elevated Indicates inflammation consistent with Crohn's disease flare-up. ESR Elevated Suggests active inflammation in the body. Fecal Calprotectin Positive Indicates intestinal inflammation, supporting Crohn's diagnosis. CBC Normal red and white blood cell counts No signs of anemia or infection. b. Diagnostic studies Name Date Result Stool Culture 23/10/2024 Negative for Clostridium difficile, ruling out infection as a cause of symptoms. CT Scan 24/10/2024 Revealed thickening of the intestinal wall, consistent with Crohn's disease activity. * List of current medications Name Dose Route Frequency Action Side effect Nursing Responsibilities D5 NS 0.45% 100 mL/hr IV Continuous Fluid and electrolyte replacement Fluid overload, electrolyte imbalance Monitor IV site, fluid balance Ciprofloxacin 400 mg IV BID (1700H- 0500H) Antibiotic Nausea, vomiting, diarrhea, tendon rupture Monitor for side effects, ensure adequate hydration Metronidazole 500 mg IV q8h (1400H- 2200H- 0600H) Antibiotic Nausea, metallic taste, peripheral neuropathy Monitor for side effects Heparin 5000 units SQ q12h (1300H- 0100H) Anticoagulant Bleeding, bruising, thrombocytopenia Monitor for bleeding, bruising, administer at correct sites Paracetamol 1 gm IV q6h Analgesic, antipyretic Liver damage (rare at this dose) Monitor liver function tests Plasil (Metoclopramide) 10 mg IV q8h PRN Antiemetic Drowsiness, extrapyramidal symptoms Monitor for side effects, assess for nausea/vomiting.

9 References APA style: 1. Crohn's disease: A case report with literature review. (2015). Advances in Research and Management. Retrieved from https://sciendo.com/article/10.1515/arsm-2015-0017 2. A case report of Crohn's disease and primary small bowel lymphoma. (2019). Revista Colombiana de Gastroenterología, 34(1), 29-34. Retrieved from http://www.scielo.org.co/scielo.php?pid=S0120- 99572019000100085&script=sci_arttext&tlng=en 3. Crohn Disease - StatPearls. (2024). In StatPearls. Treasure Island (FL): StatPearls Publishing. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK436021 * List of patient's problems or nursing diagnoses (in priority): Actual problems Potential problems (high risk) Acute Pain related to inflammation of the intestinal wall as evidenced by right lower abdominal pain rated 6/10, aggravated by touch and movement. Risk for Infection related to IV antibiotic therapy and compromised intestinal integrity. Risk for Dehydration related to decreased oral intake and chronic diarrhea as evidenced by a history of decreased fluid intake for 2 days prior to admission. Risk for Electrolyte Imbalance related to ongoing diarrhea and fluid replacement therapy. Imbalanced Nutrition: Less than Body Requirements related to dietary restrictions and nausea as evidenced by weight loss and reduced oral intake. Risk for Impaired Skin Integrity related to potential immobility from abdominal pain and prolonged bed rest. Fatigue related to chronic illness and inadequate nutrition as evidenced by reported fatigue and decreased activity levels. Risk for Thromboembolism related to anticoagulant therapy (Heparin). Altered Sleep Pattern related to abdominal discomfort as evidenced by interrupted sleep due to pain. Potential for Ineffective Coping related to emotional stress from managing a chronic illness and hospitalization. Acute Pain related to inflammation of the intestinal wall as evidenced by right lower abdominal pain rated 6/10, aggravated by touch and movement..