Lamictal 200mg daily, Lexapro 10 mg daily Weight = 210 lbs, last visit weight = 195 What other assessments should be included for this patient? What questions should the nurse ask with regard to the abdominal pain? From the readings, subjective data, and objective data, what is the most probable cause of the abdominal pain? What should be included in the plan of care? What interventions should be included in the plan of care for this patient?

Patients’ Assessments

This patient should have a full abdominal examination including palpation. Also, the digital rectal examiner must be used to look for masses, hemorrhoids and anal fissures. The nurse should also assess the patient’s dietary and fluid intake, activity level, and any recent changes in bowel habits. If the patient has recently traveled, been exposed to sick individuals, or is experiencing any symptoms like fever or diarrhea, then it’s important that you ask about this.

Ask the patient questions

Asking the patient about abdominal pain is important.

1. What was the cause of your pain?
2. How would you describe the intensity of your pain?)?
3. Is the pain spreading to other parts of your body?
4. Does the pain have any other symptoms such as nausea, vomiting or fever?
5. Are you experiencing any changes recently in your bowel movements?
6. Recent trauma in the abdominal region?
7. Do certain positions or activities make the pain worse or better?

What are the possible causes of abdominal pain?

According to the objective and subjective data, chronic constipation is the most likely cause of abdominal pain. This patient is taking laxatives and has had a long history of constipation. This diagnosis is further supported by the hypoactive bowel sound and reduced appetite.

Plan of Care

This patient’s plan of treatment should include addressing his chronic constipation as well as any other symptoms related to his condition. In the plan of treatment, include:

1. To promote regular bowel movement, increase fluid intake and fibre consumption.
2. Promote bowel motility by encouraging physical activity.
3. If needed, use a stool-softener or laxative medication.
4. Adjust the dosage if necessary.
5. Encourage your patients to adopt healthy bowel habits by educating them on how they can prevent chronic constipation.
6. Referral to a gastroenterologist is recommended for further assessment and treatment of chronic constipation.

You can also read our conclusion.

Kevin Valeri’s presentation of constipation and abdominal bloating requires a thorough assessment and evaluation to develop an appropriate plan of care. The nurse should conduct a complete abdominal exam, ask relevant questions, and consider the patient’s medical history to determine the probable cause of the abdominal pain. The plan of care should focus on managing the patient’s chronic constipation and addressing any associated symptoms. The prevention of chronic constipation can be achieved through lifestyle changes and education.