NURS 6521 Assessing Abdomen Walden University
Order ID | 53563633773 |
Type | Essay |
Writer Level | Masters |
Style | APA |
Sources/References | 4 |
Language | English |
Description/Paper Instructions Assessing the Abdomen SUBJECTIVE: CC: “My stomach hurts, I have diarrhea and nothing seems to help.” HPI: JR, 47 yo WM, complains of having generalized abdominal pain that started 3 days ago. He has not taken any medications because he did not know what to take. He states the pain is a 5/10 today but has been as much as 9/10 when it first started. He has been able to eat, with some nausea afterwards. PMH: HTN, Diabetes, hx of GI bleed 4 years ago, Medications: Lisinopril 10mg, Amlodipine 5 mg, Metformin 1000mg, Lantus 10 units qhs Allergies: NKDA FH: No hx of colon cancer, Father hx DMT2, HTN, Mother hx HTN, Hyperlipidemia, GERD Social: Denies tobacco use; occasional etoh, married, 3 children (1 girl, 2 boys) Additional subjective data listed below: Health history- diet & exercise General–Negative for fevers, chills, night sweats, and fatigue Cardiovascular– HTN, denies chest pain and palpation PMH: 1 GI surgery and 1 hospital stay related to GI bleed
OBJECTIVE: VS: Temp 99.8; BP 160/86; RR 16; P 92; HT 5’10”; WT 248lbs Heart: RRR, no murmurs Lungs: CTA, chest wall symmetrical Skin: Intact without lesions, no urticaria Abd: soft, hyperactive bowel sounds, pos pain in the LLQ Additional objective data listed below: Additional objective data should include: imbalance of electrolyte, guarding the abdominal area, or vomiting. Inspection (Abdomen is symmetric bilateral, inverted, midline umbilical), no discoloration noted to skin, negative hernia. General–Pt appears anxious and presents with guarding to abdomen Cardiovascular-Negative for murmur, cyanosis, and clubbing of fingers. Gastrointestinal–Abdomen is soft and symmetrical, negative for distention; bowel sounds are hyperactive, Negative for masses, lesions, or splenomegaly. Denies indigestion, or heartburn. Pulmonary– LCT and percussion bilaterally Diagnostics: include stool occult test, colonoscopy, liver function test, CT scan, or a biopsy. ASSESSMENT: Left lower quadrant pain Differential Diagnosis includes:
Diagnostic testing for the diagnosis listed above include stool occult test, colonoscopy, liver function test, CT scan, or a biopsy. Stool occult test would be used to determine a GI bleed. Liver function test measures the albumin, alanine transaminase, aspartate aminotransferase, alkaline phosphatase, and bilirubin to determine injury or disease of the liver (Biggers, 2017). A CT scan will give a visual of any masses or blockage within the abdomen, and a biopsy will assess tissue for diseases. Physical examination will include an assessment of the abdomen. It is essential for the inspection to be done first, followed by auscultation, palpation, and then percussion. If the assessment is done in another order, it could interfere with bowel sounds and cause false data. Inspection includes observation of the abdominal area with focus on the abdomen’s shape, abnormalities noted to the skin, masses, and abdominal wall movement with respiration. Abnormalities noted with inspection will require further assessment with auscultation and palpation. Auscultation is used to find negative bowel sounds, bruits sounds, and rubs. Palpation is used to determine crepitus of the stomach, abnormal tenderness, or masses to the abdomen. Percussion is necessary to assess the condition or underline structures of the abdomen (Ferguson, n.d.). Reference Biggers, A. (2017). Liver Function Tests. Retrieved from https://www.healthline.com/health/liver-function-tests Ferguson, C. (n.d.). Inspection, Auscultation, Palpation, and Percussion of the Abdomen. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK420/ Mayo Clinic. (2018). Crohn’s disease. Retrieved from https://www.mayoclinic.org/diseases-conditions/crohns-disease/symptoms-causes/syc-20353304 Rogers, G. (2017). Ulcerative Colitis. Retrieved from https://www.healthline.com/health/ulcerative-colitis Shahedi, K. (2017). Diverticulitis Clinical Presentation. Retrieved from https://emedicine.medscape.com/article/173388-clinical Stoppler, M. (2018). Colon Cancer (Colorectal Cancer). Retrieved from https://www.medicinenet.com/colon_cancer/article.htm#colon_cancer_facts Wedro, B. (2018). Food Poisoning Symptoms, Remedies, Treatment, and Cure. Retrieved from https://www.medicinenet.com/food_poisoning/article.htm#food_poisoning_definition_and_facts
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