NR 603 Week 8 iHuman assessment and plan - SOAP, Assignments of Nursing

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Problem statement: KF is a 45-year-old female presents today for stomach pain starting at least 10 years ago. She states that she also feels bloated at times, passing a lot of gas. The pain is all over, primarily in the lower abdomen, gets worse with rich foods and improves with bowel movements. She has also goes between periods of constipation and diarrhea. Denies any painful or bloody stools. Medical history includes headaches, hot flashes, c-section, and tibia fracture requiring surgery. Physical exam shows mild tenderness of bilateral lower abdomen to deep palpation. Denies any radiating pain, chest pressure or tightness, or difÏculty breathing. HPI: KF is a 45-year-old female who presents today for intermittent pain of lower abdomen for 10 years. She states that the pain has always been there but has been getting worse. Pain is typically worse after eating rich foods but is sometimes relieved with bowel movement. She also feels like she is bloated and producing a lot of gas. She often avoids eating due to this stomach pain. She denies any trauma or unusual events surrounding the start. Denies radiating pain, blood stools, or weight loss. She does confirm pattern of constipation and diarrhea. VS: Height: 5’4”; Weight: 141lb; BP: 118/60; HR: 60; RR: 14; Temp: 98.6F; SpO2: 98% Diagnostics: CRP: 4; Capsule endoscopy: Normal; Colon Biopsy: Normal; Colonoscopy: Normal; CBC: Normal; CMP: Normal; CT abdomen: Normal; CTA abdomen: Norma; ESR: Normal. Plan: Consults/Referrals: Referral will be made for Dietician for evaluation of dietary options and management. This patient will also be referred to GI for evaluation of treatment options and possible complications. As there can be a psychological component to IBS a referral to psychiatry will be made. Medications: Pharmacologic treatment of IBS revolves around symptom management. These medications include: Polyethylene Glycol; Take 1 capful in 4-8oz of liquid daily to produce regular bowel movements. Hyoscyamine 0.125-0.25mg sublingual; Take 1 tab every 4 hrs as need for pain and bloating. Loperamide 2mg; Take two tabs by mouth 3 times a day as need for loose stool. Education: IBS is a gastrointestinal disorder that is diagnosed by the recurrence and pattern alternating between constipation and diarrhea. This is caused by a disorder of the gut and brain that causes abdominal pain and is associated with the changes in bowel habits (Farmer et al., 2020). First line treatment for IBS is lifestyle and dietary modifications. You should participate in regular physical activity, 30 minutes 5 times per week. You should also find ways to manage stress as this has an impact on how well IBS is managed. Some stress management techniques such as Yoga and meditation are recommended. Dietary changes should incorporate dietary fiber which helps regulate bowel function and can help reduce symptoms. The dietician will provide you with more information on fiber containing foods. Follow-up: Patient will follow-up in 3-6 months for evaluation and effectiveness of treatment. During these visits the provider will also evaluate compliance with dietary and lifestyle changes. If symptoms worsen a follow-up appointment should be done sooner. If evidence of bleeding is noted the patient should continue to the ER. A reduction in fermentable olgio-, di-, monosaccharides and polyols

(FODMAP) can help improve bloating and pain. These are carbohydrates that have been found to produce gaseous distention and includes legumes, fruits, and artificial sweeteners (Farmer et al., 2020). A probiotic can be added to your diet for the further regulation of intestinal homeostasis. If you notice any bright red stools, feeling of lightheadedness, dizziness or increased fatigue go to the ER for evaluation of GI bleeding. References Farmer, A. D., Wood, E., & RufÒe, J. K. (2020). An approach to the care of patients with irritable bowel syndrome. CMAJ : Canadian Medical Association journal = journal de l'Association medicale canadienne , 192 (11), E275–E282. https://doi.org/10.1503/cmaj. General: Well nourished HEENT: Occasional headache. Denies any changes in hearing or swallowing. Denies dizziness or lightheadedness. Cardiovascular: Denis any shortness of breath, palpitations, or hear disease. Respiratory: Denies any cough, or difÏculty breathing. Gastrointestinal: Reports lower abdominal pain starting 10 years ago. Pain is constant and cramping. Does feel bloated at times with increased gas, relieved with bowel movement. Pattern of diarrhea and constipation each lasting a couple of days. Denies any causative factors such as foods. Denies any black, tarry, stools or occult blood. Genitourinary: Denies difÏculty urination, vaginal discharge, or hematuria. Musculoskeletal: Denies any joint or bone pain. No muscle cramping or stiffness. Has not noticed any swelling of any extremities. Neurologic: Occasional headaches but denies falls, numbness or tingling. Integumentary: Reports dry skin and hot flashes. Psychiatric: Denies feeling depressed and anxious Endocrine: Occasional hot flashes. Hematologic: Denies any abnormal bleeding or bruising. Allergic: NKDA PMH: Headaches, hot flashes with dry skin. Hospitalizations: C-section and bike accident with complicated fracture of tibia at 17. Preventative Health: Up to date immunizations including flu shot. No colonoscopy or mammogram.

Medications: OTC multi-vitamin and Tylenol for headaches. Allergies: NKDA Social History: Lives at home with husband. Reports glass of wine with dinner. Denies tobacco or drug use. Family History: Maternal: arthritis PE: General: Stressed/anxious sitting upright in bed, marked increase in respiratory effort. Catches breath midsentence. HEENT: Non-tender, no masses, lesions, deformities, or edema. Eye: no ptosis, erythema or swelling, no discharge, PERRLA. No polyps or discharge in nostrils, no frontal or maxillary sinus tenderness. Cardiovascular: Normal heart sounds, S1 and S@ noted, no murmurs, clicks, or rubs noted. Chest/Respiratory: Lungs clear bilaterally. Symmetrical chest expansion, no retractions or accessory muscles noted. Abdomen: Abdomen flat and symmetric, normoactive bowel sounds in all four quadrants. Mild tenderness with deep palpation of lower abdomen. Genitourinary: normal female external genitalia, no masses, tenderness, or discharge. Musculoskeletal: No edema of feet and ankles, normal ROM, and strength Neurologic: Alert and oriented x 4, DTR WNL. Skin: warm and dry with no lesions seen, hair thickness and distribution normal for age. Lymphatic: no enlarged lymph nodes in the cervical, supraclavicular, axillary, or inguinal chains Psychiatric: Cooperative and appropriate interactions.