Pt Initials: EM 14yo female ADX: perianal pain HPI:Patient presented to ED on 6/19/2016 for perianal pain reporting pain 9 out of 10 for 2.5 wks. Upon examination EM presented with exacerbated rectal fissures with open blisters, bleeding and erythema in the surrounding perianal area. She has a long-standing history of atypical IBD complications to include anal structures, inflamed rectosigmoid and rectal structure. Last week she was prescribed PRN steroids but reported that they were not helping. In 2015 an ileoscopy/EGD was performed and revealed normal results. The decision has yet to be made whether to create a permanent ileostomy vs maintaining therapy in an effort to regain integrity of a complete GI system.
Vitals: HR 78, T 36.3, Resp 16, BP 106/62, O2 98% on Rm Air
A Coggle Diagram about Imbalanced nutrition (Provide food of choice, provide frequent meals, educate about the role of nutrition in wound healing, ambulate/encourage activity to "work up appetite", Limit fluids during meals, provide nutrient dense foods, obtain diatary consult, mx clean relaxed envronment, Observe and report signs of infection such as redness, warmth, discharge, and increase body temperature and Carefully wash and pat dry skin, including skinfold areas. Use hydration and moisturization on all at risk surfaces), Risk of Infection (vitals q4, antibiotics as ordered, utilize sterile technique for procedures involving open wounds, prevent nosocomial pneumonia: assess lung sounds, sputum, redness or drainage, contact precautions to protect patient, hand hygine and encourage adequate rest), Impaired Skin Integrity and Ineffective Coping (Therapeutic communication to help EM develop increased self confidence and develop coping strategies when feeling frustration and anxiety, Referral to teen support group related to complex medical diagnosis. and Referral for parent to learn how to better support childs emotional needs)