Handover: Mr Eddie Baker is 31 years old. He was diagnosed with Crohn’s disease in his early 20s. Since then, the disease process has become extensive, affecting most of his terminal ileum and ascending colon. He has experienced some severe exacerbations which have required hospitalisation. He has used most of the pharmacotherapies available, including immunosuppressive medications and corticosteroid therapy for acute exacerbations.
Recently, after a colonoscopy showed progression of the disease to other sections of his large bowel, he made the decision to undergo a total colectomy to better manage his condition.
His initial surgery was booked for yesterday at 1000. He last ate at 1930 the night before his surgery and last drank at a black weak tea at 0600 the morning of surgery. Due to an emergency Eddie’s operation was delayed until the afternoon. The surgical team were happy with the operation and reported minimal blood loss. Eddie returned to the ward at 1900 last night.
It is now 0700 and you have received morning handover from the night shift.
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NURSING DIAGNOSES, GOALS, ACTIONS, RATIONALE and EVALUATION (word count 800) |
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Nursing diagnosis 1: (not included in word count) >>insert text here<< |
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