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. 

Scene 1

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. 

Scene 2

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. 

Scene 3

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. 

Scene 4

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. 

Scene 5

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. 

Scene 6

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. 

Scene 7

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. 

Scene 8

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.. 

Scene 9

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.

1 Crohn s disease