Concept Map Crohn's Disease - Medical Dx/Problem: Crohn's...

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Medical Dx/Problem: Crohn’s Disease Data: O: Pt has been the hospital 2 weeks with a no contact order. Pt has MRSA, pt on TPN, IV’s, wound vac and has an ileostomy. S: Absence of supportive significant others. Sad, dull affect. Nrs Dxn: Social Isolation Outcomes: (Pt will) Pt’s wounds will heal enough to remove the wound vac by the end of the week. MRSA infection will resolve, no contact order will be removed. Nrs Dxn: Impaired tissue integrity Nrs Dxn: Imbalanced nutrition less than body requirements. Nrs Dxn: Acute Pain Data: O: NPO diet until today started on clear liquids. TPN. Admit weight 82 kg, today’s weight 79 kg. Total removal of pt’s colon. Crohn’s disease. S: Decrease in subcutaneous fat/muscle. Loss of weight while receiving TPN. Data: O: Pt guarding abdomen upon palpation, increased heart rate Abscess draining, 2 wound vacs over old ileostomys. S: “My abdomen hurts, about a 7-8/10.”; “I think I need some pain medication for it.” Data: O: Nutritional factors, NPO,
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This note was uploaded on 04/21/2011 for the course NURSING 105 taught by Professor Copeland during the Winter '09 term at Grand Valley State University.

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