Walden University – NURS 6512 Week 6 Assignment 1 Lab Assignment: Assessing the Abdomen Sample Essay
Walden University – NURS 6512 Week 6 Assignment 1 Lab Assignment: Assessing the Abdomen Sample Essay
Walden University – NURS 6512 Week 6 Assignment 1 Lab Assignment: Assessing the Abdomen Sample Essay
Abdominal Assessment
Nurses and other healthcare providers play an important role in the promotion of health of diverse patient populations. They utilize their knowledge and skills in patient assessment to determine the actual and potential health needs of their patients. Abdominal health problems are part of the conditions that nurses address in their daily practice. Therefore, this essay examines a case study of a patient that came with abdominal health problem. The patient is a 47-year-old male that complained of generalized abdominal pain, which started 3 days ago. The essay examines the additional subjective and objective data that should be obtained from the patient, diagnostic investigations, and differential diagnoses that should be considered.
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Subjective Analysis
Subjective information refers mainly to the data that healthcare providers obtain concerning the experiences of the patients with a health problem. Subjective data explores a wide range of aspects of a disease such as the concerns and feelings of the patient. A number of subjective information should be obtained from JR. One of them is the character of the abdominal pain. Besides the rating and intensity of the abdominal pain, questions related to aggravating, precipitating and relieving factors should be obtained. There is also a need to obtain information on whether the pain radiates to other parts of the body, generalized, increasing or decreasing in severity or not. Information about the pain such as its character such as being gradual or of sudden onset should also be obtained. Additional information about the diarrhea should also be obtained. For example, the frequency and number of diarrhea experienced in a day should be obtained. This is important as it provides clues into the hydration status of the patient. Information about the aggravating, precipitating, and relieving factors for diarrhea should also be obtained (Perry et al., 2021). Recent dietary history and habits should also be explored to determine the potential cause of the health problem. The history obtained from the JR indicates that he has a history of GI bleeding. It is therefore important to ask information related to whether there is blood stained stool, smell and color to determine the exact cause of the problem. Comprehensive acquisition of subjective information is therefore crucial to guide the development of the most accurate diagnosis for JR. Get help with nursing paper. Assessing the Abdomen Sample Essay from experts
Objective Analysis
Objective data refers to the information that the healthcare provider obtains through physical examination. It entails the use of techniques such as observation, auscultation, percussion, and palpation. Objective data is mainly used to validate subjective data and develop accurate diagnosis of a problem affecting a client. A number of objective data needs to be obtained from the client in the case study. The first aspect of objective data is documenting the general appearance of JR. Information about the general appearance of the patient such as if well dressed and sick looking should have been obtained. Patients with chronic illnesses such as colon cancer may appear lethargic and malnourished. JR should have also been examined for jaundice and hydration status. Inspection of the abdomen should also be done to determine whether there is abdominal distention. Abdominal distention may lead to the development of diagnoses such as organomegally or pancreatic cancer. Observation should also aim at determining if there are any scars and distended veins. Palpation should also be done to determine if there is abdominal rigidity, tenderness, or rebound tenderness. Rigidity could indicate accumulation of fluid or abdominal matter in the peritoneal cavity, hence bowel obstruction (Cox, 2019). Therefore, the above objective data would guide the development of accurate diagnosis for the client. Order for an essay like Assessing the Abdomen Sample Essay from experts nursing writers.
If the Assessment is supported by Subjective and Objective Information
The assessment in the case study is supported by objective and subjective information. As noted initially, subjective data focuses on the perceptions and feelings of the patient with a disease. JR reported subjective data such as diarrhea and vomiting. He also reported pain and history of GI bleeding. Objective data focuses on the information that the healthcare provider obtains through physical assessment (Estes et al., 2019). The data such as vital signs, absence of murmurs, and intact skin without lesions are some of the objective information in the case study.
Diagnostic Tests
Additional diagnostic tests should be performed to come up with an accurate diagnosis of the health problem that the client in the case study is experiencing. One of the tests would be stool occult test to determine if there is blood in the stool or not. The other test is complete blood count to determine if the client has infection. Liver function tests may also be performed to determine whether there is an abnormality with liver enzymes, which indicate liver disease. Ultrasound of the abdomen may also be needed to view the abdominal organs for any abnormality (Williams, 2021).
Accepting or Rejecting Diagnosis and Possible Conditions
The assessment was not comprehensive. For example, it did not examine the lower quadrant pain to determine its character. The subjective data points towards a possible diagnosis of gastroenteritis. The presence of abdominal pain, low-grade fever, vomiting and nausea are often associated with gastroenteritis. One of the differential diagnoses for JR in this case study is abdominal obstruction. Patients with abdominal obstruction often experience symptoms such as abdominal pains, vomiting, nausea, and vomiting. However, this condition is least likely due to the presence of diarrhea (Perry et al., 2021). The other possible differential diagnosis is pancreatic cancer. Patients with pancreatic cancer may experience symptoms such as abdominal pains, nausea, and vomiting. However, this should be ruled out by performing comprehensive history taking and physical examination. Diagnostic investigations such as abdominal ultrasound will help determine if JR is suffering from pancreatic cancer. The last differential diagnosis is diverticulitis. Diverticulitis is also associated with left lower quadrant pain, nausea, fever, and vomiting (Williams, 2021). The condition should be ruled out through a CT scan of the abdomen.
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Conclusion
In conclusion, comprehensive assessment and physical examination is important in patient care. Additional subjective and objective data should be obtained from the patient in the case study to develop an accurate diagnosis. In addition, diagnostic investigations should be done to determine the actual cause of the abdominal problem. Differential diagnoses should be considered to guide the development of the treatment plan.
References for the Assessing the Abdomen Sample Essay
Cox, C. L. (2019). Physical Assessment for Nurses and Healthcare Professionals. John Wiley & Sons.
Estes, M. E. Z., Calleja, P., Theobald, K., & Harvey, T. (2019). Health Assessment and Physical Examination. Cengage AU.
Perry, A. G., Potter, P. A., Ostendorf, W., & Laplante, N. (2021). Clinical Nursing Skills and Techniques—E-Book. Elsevier Health Sciences.
Williams, P. A. (2021). Fundamental Concepts and Skills for Nursing—E-Book. Elsevier Health Sciences.