The bowel movements frequency, color and consistency should be included in the history. Whenpatient mentions use of alcohol, the type of the alcohol, amount, and frequency of consumption is important information that needs to be gathered documentation. The times patient takes the medications listed above and the last time taken needs to be disclosed. Educational and work history should be included in the social assessment. The subjective assessment should have included a complete review of systems to reveal symptoms that the patient may have forgotten ordeemed unimportant to further aid in finding a diagnosis.Additional objective information neededAs an advanced practitioner a thorough head to toe assessment must be performed and included in the documentation. An examination of all the systems is deemed necessary for everypatient that comes for with a chief complaint seeking care. Vital signs, heart, lungs, skin, © 2014 Laureate Education, Inc.Page 2 of 7
abdominal are the assessments noted, the advance practitioner must complete the rest of the systems deemed necessary. Skin color should be included to see if jaundice is present. The temperature route and whether its Celsius or Fahrenheit needs to be included. Additional abdominal assessment such as palpation to assess for masses and tenderness, and percussion should be included in the objective assessment. Percussion is used to access the organs size and to detect fluid presence. Palpation could reveal organ enlargement of the liver and kidneys and percussion can assist in identifying ascites. An assessment of the groin is also important to rule out an inguinal hernia and testicular torsion.Is the Assessment Supported by the Subjective and Objective Assessment?The diagnosis of gastroenteritis cannot be supported from the information obtained from the objective and subjective assessment. The subjective assessment has limited and incomplete information to get the full picture. The objective assessment is incomplete and needs the assessment of the other systems to rule out other diagnoses and support the diagnosis of gastroenteritis. No diagnostic testing was performed to further confirm the gastroenteritis.
You've reached the end of your free preview.
Want to read all 7 pages?
- Summer '15
- Gastroenterology, Irritable bowel syndrome