(Answered) NURS 6512 Week 6 Lab Assignment; Assessing the Abdomen

COURSE  

NURS 6512 Advanced Health Assessment and Diagnostic

Subjective:

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 3 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 afterwards
  • 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 PLAN: This section is not required for the assignment.

Additional Documentation Information

Is the assessment supported by the subjective and objective information?

Pt presents with c/o generalized abdominal pain, nausea and diarrhea x 3 days. The c/o generalized pain should be assessed further to determine the origin and if pain radiates from the left lower quadrant. The intensity, character and the frequency of pain needs to be determined. Since abdominal pain can be mistaken for back pain, the provider should assess the musculoskeletal system in addition to the liver, kidneys and pancreas.………please click the icon below to purchase full answer at $10