WK6Assign1CunninghamJ(NURS 6512).edited.doc - RUNNING HEAD Assessing the Abdomen 1 Lab Assignment Assessing the Abdomen Joanna Cunningham Walden

WK6Assign1CunninghamJ(NURS 6512).edited.doc - RUNNING HEAD...

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RUNNING HEAD: Assessing the Abdomen 1Lab Assignment: Assessing the AbdomenJoanna CunninghamWalden UniversityNURS 6512, Advanced Health AssessmentOctober 7, 2019Abdominal Assessment
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RUNNING HEAD: Assessing the Abdomen 2Subjective: • 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 three 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 afterward. • 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) 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 • Diagnostics: None Assessment: • Left lower quadrant pain • Gastroenteritis Subjective AnalysisThe information regarding abdominal pain and diarrhea are very vague. According to Dains et al., (2019), abdominal pain is a subjective feeling of discomfort in the abdomen that canbe caused by a variety of conditions. Characteristics, timing, and frequency of pain patient need to be explained. Is the pain dull, throbbing, sharp, cramping, aching, shooting, or stabbing? When did the pain start? Does anything aggravate the pain? Are there any alleviating factors forpain? How often is diarrhea? What color is diarrhea? When did diarrhea begin? Is there
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RUNNING HEAD: Assessing the Abdomen 3cramping or pain associated with diarrhea? After analysis of the subjective portion of the note, the Review of Systems is also needed to complete a proper examination. The Review of Symptoms describes and symptoms the patient is experiencing in the present or past. In the givencase study, the review of systems should include General, HEENT, Skin, Cardiovascular, Respiratory, Gastrointestinal, Genitourinary, Neurological, Musculoskeletal, Hematological, Lymphatics, Psychiatric, Endocrinologic, and Allergies. The additional subjective questions to beanswered to assist in the completion of the ROS would be as follows:General: How is your appetite? Any recent weight gain or loss? Do you feel tired or have energy? Any night sweats?HEENT: Are you having any vision issues? Any ringing in the ears, dizziness, ear pain, or drainage? DO you have a runny nose or stuffy nose? Have you ever experienced a bloody nose?
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