Assessing the Abdomen Subjective/Objective Data

Assessing the Abdomen Subjective/Objective Data
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  Running Header: Assessing the Abdomen 1 Assessing the Abdomen Kizzie Houston  NURS 6512 Advanced Health Assessment Walden University April 7, 2019  Running Header: Assessing the Abdomen 2 Subjective/Objective Data Soap notes are tools used to document comprehensive assessments. Soap notes contain the subjective data or what the patient tells the practitioner and objective data, information gathered by observation. In the example soap note the subjective section the review of system section was omitted, no mention of past surgeries, complete head-to-toe assessment or laboratory data collected. Completing a review system allows the practitioner to explore any positive responses, in this case there is need to focus on the gastrointestinal system due to the history of GERD and the complaint of abdominal pain and diarrhea. The clinician should ask about gas,  bloating as these are signs of irritable bowel disease. The patient complained of abdominal pain and diarrhea, so the H&P should include questions to assess for dehydration such as: are you thirsty? Are you experiencing dry eyes or dry mouth? Diarrhea can be caused by medications, inflammatory bowel diseases, food  poisoning, and parasite invasion. Assessing whether the patient has taken any antibiotic recently for infections could be helpful to rule out c. difficile. Antibiotics can disturb the normal flora in the stomach and this results in diarrhea. The patient is taking metformin for diabetes and this medication cause digestive disorders. Huang et al., states gastrointestinal side effects are observed in 30% of diabetic that take metformin. Left lower quadrant pain can be indicative of diverticulitis, impaction, or IBS. The consistency of the stool is covered in the assessment; however, the color Is also important to assess. According to Dain, Baumann, and Scheibel (2016), stools that are yellow or green can contain undigested food, mucus, and blood. Black tarry stools are indicative of bleeding from the upper GI tract and bright red blood may indicate a lower GI bleed, hemorrhoids, or a mass (Dain et al.,  Running Header: Assessing the Abdomen 3 2016). The patient has a history of GI bleed, so it would also be important to ask about blood transfusions. Differential Diagnosis 1.   Gastroenteritis 2.   IBS 3.   Diverticulitis 4.   Crohns 5.   Gastritis Diagnosis: Gastroenteritis Accepted/rejected: Accepted Additional possible diagnoses: gastroenteritis, inflammatory bowel disease, acute diverticulitis Rationale for accepting the diagnosis: The disease is characterized with the following symptoms: diarrhea, nausea, abdominal pain, and vomiting. The patient reports being able to eat but he gets nauseated. He could have possibly contracted this disease via mishandled foods, water, or person to person contact. The symptoms started three days ago and can last up to 10 days. The patient has hyperactive bowel sounds and this is indicative of gastroenteritis. The most common cause of acute diarrhea is gastroenteritis.  Nausea, diarrhea, and vomiting are three of the top diagnoses for gastrointestinal disorders. Gastrointestinal disease occurs when there is a disruption in the physiological process.  Running Header: Assessing the Abdomen 4 Gastroenteritis is a diarrheal disease that occurs rapidly with or without nausea, vomiting, fever, and abdominal pain (Ibrahim, Palalian, Al-Sulatti, & El-Sham, 2016). The patient reports being able to eat but he gets nauseated. He could have possibly contracted this disease via mishandled foods, water, or person to person contact. The symptoms started three days ago and can last up to 10 days. The patient has hyperactive bowel sounds and this is indicative of gastroenteritis. The most common cause of acute diarrhea is gastroenteritis. Establishing a plan of care and rationale for gastroenteritis include assess the patient’s loss of volume. Ask the patient about the number of stools and vomitus episode. Assess the  patient for dehydration, hypotension, and low blood pressure. Lomotil can be prescribed for loose stools but should be avoided in patients with diarrhea stool. Phenergan can be prescribed for nausea and vomiting but this medication can cause hypotension, but the patient takes medication for hypertension, the blood pressure must be monitored. Treatment for gastroenteritis include parenteral fluids to restore fluid balance. Gastroenteritis is self-limiting and does not require any antibiotics. The practitioner should encourage the patient to increase their fluid intake, avoid concentrated sugary drinks, alcohol, and caffeinated drinks because these drinks can contribute to lose stools. Ask the patient about the onset of symptoms, travel history, and health of family members to rule out food poisoning (Townes, 2014). IBS is characterized by abdominal pain and alterations in bowel habits. Irritable Bowel Syndrome present with altered gut microbiota that either increases bowel motility (diarrhea) or decreases bowel motility (constipation). Some food antigens can activate the immune system and cause IBS symptoms. Irritable bowel disease can cause diarrhea, bloating, early satiety, abdominal pain, and fatigue (Skratins & Fletcher, 2018). Corticosteroids, methotrexate,  Running Header: Assessing the Abdomen 5 thiopurine drugs can be uses to treat IBD and IBS (Filatova, 2016). Cannabis can also be used as an alternative method to treat IBS and IBD. The onset of IBS-like symptoms can occur in  patients after an episode of diverticulitis (Moayayedi et al., 2017). IBS can also be caused by triggers such as stress. There is no test to confirm IBS; however, recurrent abdominal pain and abnormal bowel habits are defining features of the disease (Moayayedi et al., 2017). The most common cause of left lower quadrant pain is in adults is diverticulitis in either the descending or sigmoid colon. Diverticulitis is the inflammation of the diverticula which is normally caused by inadequate fiber in the diet. People with diverticulitis will have left lower quadrant pain. Diverticulitis should be suspected if the patient has left lower quadrant pain, fever, and leukocytosis (Mattson & Dulaimy, 2017). Signs and symptoms of diverticulitis include nausea, vomiting, diarrhea, chills, and abdominal pain. A cat scan of the abdomen and  pelvis with contrast is recommended to diagnose diverticulitis. Crohn’s is a form of irritable bowel disease that can affect any part of the gastrointestinal tract from the mouth to the anus (George & Math, 2018). Crohns typically presents slowly but can also present as an acute illness. Symptoms include diarrhea, abdominal pain, rectal bleeding, fever, weight-loss, and fatigue (Veauthier & Hornecker, 2018). A fecal calprotectin test can rule out Crohn disease in adults. There is usually some small bowel involvement and the disease can mimic other diseases such as irritable bowel syndrome and appendicitis. Diagnosis can be made via colonoscopy with biopsy. Fever is usually not present in the diagnosis. Gastritis is inflammation of the stomach mucosa. Gastritis can be acute or chronic. Acute gastritis is can be resolved by removing the irritant or factor. Chronic gastritis is more severe and involves the antrum and results in blockage of the duodenum. Complete blockage causes the stomach to lose its ability to contract and the increase accumulation of undigested
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