Nursing care plan on two diagnoses.
Patient male 52 DOB 9/25/1971
Chief complaint- coming home post op from colostomy 13 days ago 10/10 abd pain with blood noted in a colostomy bag. reported a fever of 101.5. Tachycardia hr in the 140s, initial bp 90s/40
History of present illness- 53 yr old male, diagnosed with rectal cancer awaiting chemotherapy, discharged from hospital on 10/26/23 to rehab after admission for an abscess of the gluteal region with malignant fistula and incontinence. The patient underwent bilateral dorsal transversus abdominis plane block with laparoscopic sigmoid loop colostomy creation. Presented to the emergency department from the rehab facility complaining of worsening foul smelling drainage through the gluteal region associated with pain
The first diagnosis is an abscess of the gluteal region with a malignant fistula.
The second diagnosis is rectal cancer. And the medication he is on is Cefepime, vancomycin for antibiotics and Dilaudid for pain.
This patient has no allergies.
Need to find
* Nursing assessment plan
*Nursing diagnosis for both medical diagnoses
Social history- Denies alcohol use, Substance abuse- Marijuana
Lab results and care plan instructions are attached.