Assessing the Abdomen

Digestion, motility, and absorption are gastrointestinal system processes that supply nutrients to all cells within the body. Disruption within the GI could have effects that infiltrate other systems causing side effects outside of the digestive tract. By efficient and effective thorough documentation, the practitioner can account for all symptoms related to illness to determine possible disorder. By asking specific questions both subjectively and through visual assessment one can detect changes in function. The learner will critique a SOAP note and defend or refute the documentation with differential diagnoses.

Subjective Data

The data gathered on the patient is lacking essential information that could be used in the diagnosis of the patient’s symptoms. It is crucial to obtain a thorough history of the patient, family, and specific abdominal complaints by detailing characteristics about them to generate proper diagnosis (Jarvis, 2011). The history of present illness should incorporate data like onset, duration, characteristics, exacerbating, and alleviating symptoms as it relates to abdominal pain. Location is one of the most critical questions to ask before the beginning exam (Ball,2015). To reframe from exacerbating pain more, the practitioner should avoid palpating the area until the very end. This allows for a thorough assessment. Simple differentiation of sharp verses dulls generalized pain could signal the organs associated with the symptoms experienced (Dains, 2016). It is also critical to determine the characteristic of the other symptoms related to a stomach ache. The gastrointestinal disease usually manifests in the presences of at least one or more of the following: change in appetite, weight loss, dysphagia, nausea and vomiting, changes and bowel habits (2011).

In the subjective information provided the lack clarity in description of accompanying symptoms According to Ball, subjective assessment should include questions about diet including a 24hour history of meals, last bowel movement and characteristics thereof, recent travel history would also be useful information to note to account for suspected contracted GI disorders (Shaw, 2012). The family history of the patients seems to be completed; however, the patient’s personal history lacks detail. More information regarding his GI bleed would be a good place to start. Asking about whether it was an upper or lower GI bleed, diagnostics performed, results, medications used, complications, or the need for surgery and post-op care (2012). Comorbidities of the patient are also essential along with listed over the counter medications. Aspirins and the use of NSAIDs may cause abdominal pain and increase the likelihood of GI bleeds; therefore their application along with dietary supplements should be included within the report (Jarvis, 2011). Lifestyle risk factors are noted; however, the frequency and duration of alcohol consumption should be included. Excessive Alcohol consumption is a risk factor that could lead to liver cirrhosis and esophageal varices (2012).

Objective Data

The objective assessment is the foundation of health care. Engaging the in act of gathering information about the patient is one of the first skilled taught a developed as it is the first step of the nursing process ( Phillips et al., 2017) Upon examining the objective information provided it would have been advantageous to start with a general audit of the patient during the assessment. Including elements of orientation, current discomfort, brief psychosocial could give additional information about the chief complaint (2017). Overall this follows the guidelines of an expanded problem focused SOAP covering affected organ systems (Sullivan, 2019). An affected organ system not listed would be HEENT since the assessment of these could preclude allergy issues, esophageal issues, sensitives to smell, increased mucous since most of the immune system is within the digestive tract. Overactive immune response or changes in the gut bacteria can be triggered by allergies (Gigante et al., 2011). Upon review of the vital signs noted, increased temperature and blood pressures could imply the patient discomfort during the visit. The integumentary assessment could have been documented as only the exception which would justify the documentation. Other information that should be included if warranted for skin would be turgor, capillary refill, and mucous membranes to assess for dehydration (Ball, 2015).

The abdominal assessment is performed with inspection and a combination of auscultation, percussion, and palpitation (Jarvis, 2011). From reading the objective note both auscultation and palpitation are used. One could assume inspection as well. Overall the note lacks the depth of the findings associated with these three methods of assessment. Was there the presence of any budges, masses, or hernias? Hyperactive bowel sounds suggest that intestines are transporting foods and fluids at an increased rate which would assist in the assessment process to determine the probable cause of visit (Shaw, 2012). During palpation, the practitioner assesses texture, tenderness, temperature, moisture, pulsations, masses, lymph nodes, and internal organs. Information documented should briefly address the finding during this process (2012). The location of the abdominal pain is noted. However, there is a classification of abdominal pain. Is it Visceral, Parietal, or referred? According to Dains, each of these classifications of abdominal pain are specific and differ from each other in location, characteristic, and onset (2016). Overall, the PQRST pneumonic could be used to gather information that is possibly left out. Correctly, this pneumonic assesses provocative, quality, region, severity, and timing for symptoms related to the chief complaint.

Assessment Data

The lack of a Diagnostic test associated with the assessment is also an error in assessment. With a patient history of a GI bleed the labs that would be significant initially would be a complete blood count. A primary metabolic panel could assess for dehydration, liver dysfunction, cirrhosis, or hepatitis (Merck, 2018). Stool cultures may also be obtained to assess for signs of infection, inflammation, or other digestive disease or disorders (Caul, 1996). The Blumberg sign could also be initiated to test for peritoneal irritation (Wholihan & Tilley, 2016). CT scans and X-ray are used to assess for blockages.

The information from the assessment ruled that the patient was suffering from left lower quadrant discomfort and gastroenteritis. This assessment seems to be minimally supported by both objective and subjective content. The patient did report pain; however hyperactive bowel sounds were noted on auscultation. Since most of the assessment lacked vital information such as history, diagnostics, symptoms of illness, differential diagnosis, diet, and comorbidities, supporting the evaluation is futile. Viral gastroenteritis is an acute disease accompanied by diarrhea, fever, abdominal pain, and nausea (Bresee et al., 2012). Common characteristics of history suggest an intermediate incubation period of 24 to 60 hours with a short period of infection lasting no longer than two weeks. Upon assessment, mild diffused abdominal tenderness is noted, with voluntary guarding possible. Decrease skin turgor, altered mental status, and dry mucous membranes would support apparent dehydration (2012). Within the assessment portion, a differential analysis is warranted to discuss decision more thoroughly. There should be a union of subjective and objective proof to lead to an assessed conclusion (Ball, 2015). With the given information, the learner would move to support the diagnosis as documented.

Differential Diagnosis

The three differential diagnosis

1. Bacterial Gastroenteritis

2. Diverticulitis

3. Gastritis or Ulcer

Evidence rejecting Bacterial Gastroenteritis is the symptom profile associated with it. Patients diagnosed with this form of gastroenteritis report high fever, serous bloody stools, anorexia with nausea being the most common in emergency clinic settings (Chan, 2003). The trademark side effect is its duration which is for longer than 14 days. If this would be the diagnoses, microscopic cultures that would indicate the presence of Campylobacter, salmonella or enteropathogenic E. Coli. There is no documented manifestation of either or test to support this diagnosis.

Evidence rejecting gastritis is the lack of pathological factor. H. Pylori is commonly observed with this diagnosis. Also, family history of the patient doesn’t detail a history of gastritis or H pylori disease which is associated with diagnosis ( Tsay & Hsu, 2018). The patient has no history of autoimmune disorders or hypersensitivity that could cause gastritis. The patient does have a vague alcohol assessment which could support the diagnosis. Overuse of alcohol could destroy the mucosa of the lumen exacerbating gastritis (2018). Side effects associated are upper abdominal pain whereas our patient has lower abdominal pain. Associated with ulcers the patient may develop dizziness, black tarry stools, weakness, paleness, shortness of breath. These side effects were not documented (2018). Diagnostics would suggest testing for the pathological antigen, occult blood, and complete blood count.

Evidence rejecting Diverticulitis is the lack of obstruction. The patient did express left lower quadrate pain which made this diagnosis worth considering since it occurs in the sigmoid colon. Most common side effects associated however is constipation, bloating, and nausea. Acute urinary issues are possible as well. The assessment would suggest diminished bowel sounds where the finding for the patient was hyperactive with diarrhea (Lorenzo & Shifflette, 2017). The suspected patient tends to have general guarding and tenderness upon assessment laboratory finding would show leukocytosis which could confirm the diagnosis. Phosphates, bilirubin amylase, and lipase levels may be collected if perforation or diffused peritonitis is apparent. The stool would be used to rule out infectious etiologies (2017).

Conclusion

Finding alterations within the gastrointestinal assessment could indicate likely issues that require sound knowledge and understanding of assessment to determine correct diagnosing and plan. Since assessment is the first step of the nursing process, understanding all implications necessary for a full focused noted for gastrointestinal findings allows for clear insight into the plan and intervention. With a clear understanding, the practitioner can intervene quickly and appropriately to the identified disorder.

References

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015). Seidel's guide to physical examination (8th ed.). St. Louis, MO: Elsevier Mosby.

Bresee, J. S., Marcus, R., Venezia, R. A., Keene, W. E., Morse, D., Thanassi, M., Glass, R. I. (2012). The Etiology of Severe Acute Gastroenteritis Among Adults Visiting Emergency Departments in the United States. The Journal of Infectious Diseases, 205(9), 1374-1381. doi:10.1093/infdis/jis206

Caul E. O. (1996). Viral gastroenteritis: small round structured viruses, caliciviruses and astroviruses. Part I. The clinical and diagnostic perspective. Journal of clinical pathology, 49(11), 874–880.

Chan, S. S. (2003). Acute bacterial gastroenteritis: a study of adult patients with positive stool cultures treated in the emergency department. Emergency Medicine Journal, 20(4), 335-338. doi:10.1136/emj.20.4.335

Dains, J. E., Baumann, L. C., & Scheibel, P. (2016). Advanced health assessment and clinical diagnosis in primary care (5th ed.). St. Louis, MO: Elsevier Mosby.

Gigante, G., Tortora, A., Ianiro, G., Ojetti, V., Purchiaroni, F., Campanale, M., Gasbarrini, A. (2011). Role of Gut Microbiota in Food Tolerance and Allergies. Digestive Diseases, 29(6), 540-549. doi:10.1159/000332977

Jarvis, C. (2011). Physical examination and health assessment, (6th ed.). St. Louis:

W.B. Saunders.