N101L - Patient Profile Database (2) GI BLEED 2021
J.L. is a 36-year-old female who is 5’6” weighing 109 lbs who was admitted to the hospital for abdominal pain, dizziness and bloody stool. J.L. has a history of Crohns disease and intermittent gastritis. J.L. had surgery and an ileostomy 6 months ago. Upon admission, a physical assessment of J.L. found serosanguinous fluid leaking from ostomy bag. J.L. is A&Ox3. Current medications include: Infliximab IV 6 months ago – her last dose was given 7 weeks ago. Ibuprofen PRN. No other prescribed medications. Vital signs upon admission include: Temperature: 99.8, Pulse: 114 beats per minute, Respiration: 22 breaths per minute, Blood Pressure: 100/60 mm Hg and Oxygen Saturation: 95% on room air. Hemoglobin is 7 mg/DL and Hematocrit: 21 %. The skin is pale, warm, and dry to the touch. Braden Scale risk assessment is 17. Morse Fall Risk is moderate. Nail beds pink, capillary refill good. Mouth/throat: pink, dry, no lesions. Heart Rate elevated, S1 and S2 normal, breath sounds clear. Patient reports pain “on top of the stomach beginning this morning” and rates pain a 6 out of 10. Patient reports stress increases pain causing her to “get headaches and taken Ibuprofen.” Abdomen is soft and flat. Hyperactive bowel sounds present. Moderate tenderness.
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- September 29, 2022
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