Abdominal Assessment
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Abdominal Assessment
Performing a thorough assessment is an essential skill. The treatment for any client is based on the diagnosis, and that diagnosis relies entirely on the assessment. To assess a 78-year-old male with a chief complaint of abdominal pain, bloody diarrhea, fever, and weight loss; there are many important factors to take into consideration. First, it is crucial to assess more in-depth the chief complaint, known as a history of current illness. These will include an assessment of the abdominal pain following the pqrst. Also, an assessment of his bowel movement (diarrhea), when did it started, what causes it, what makes it subsides; did he took anything to stop it, did he had any changes in his eating habits, ask him to describe his bowel movements, and did any nausea or vomiting accompany it. Next, an assessment of the fever to find out when did start it, what was his highest temperature reading, what causes the fever to subside, was he exposed to any diseases like Clostridium difficile or food poisoning and is it accompanied by chills. Additionally, an assessment of his weight loss to see how much weight did he lost and in how long, was the weight loss intentionally, what type of diet does he follows, is there any cultural or belief factors that affect his diet.
After the history of the current illness is obtained, the assessment continues into the risk factors. These will include a list of medications, and if the client is taking any NSAIDs or blood thinners; food, drugs, and environmental allergies; use of tobacco, alcohol and recreational drugs; history of vaccinations and traveling out of the country; past medical history (PMH), past surgical history (PSH), family history, previous hospitalizations, history of previous gastrointestinal (GI) problems like GERD, peptic ulcers, inflammatory bowel disease (IBD), anemia, and celiac disease, history of previous diagnostics GI tests and results like endoscopies and lab work. Also, assessment of living conditions, whom does he lives with, who prepares his meals, does he has access to drinking water and electricity. Even though certain diseases are not common in the US, the healthcare provider should never exclude them from the assessment. Assessing for parasitic diseases is a critical component for patients with GI symptoms and fever. Even though is more common in developing countries, it should not be ignored in the US. Commonly caused by ingestion of contaminated food or water, parasitic diseases are often misdiagnosed for tumors. The common symptoms are abdominal pain, diarrhea, bloody stool, fever, and weight loss (Çiftci, Bulut, Özdaş & Yıldırım. 2018). Amebomas are variable in sizes and on assessment are found as a palpable mass that causes obstructive symptoms and mimics many other diseases.
The next step is the physical examination. These start with the inspection, looking for the color, contour, size, shape, pulsations, and lessions (Jensen, 2015). Then, the assessment continues with the auscultation of the bowel sounds over the four quadrants and the vascular sounds. The next step is percussion of the four abdominal quadrants assessing for the size of the organs and looking for tympanic sounds over the hollow areas and dullness over the organs, masses, fluids or obstructions (Jensen, 2015). The palpation is performed at the end, beginning with light palpation and assessing for pain, then follow by deep palpation to check for organs, masses, or tenderness (Jensen, 2015).
The documentation of the assessment findings is done using the SOAP format. All subjective data is documented under S, and all objective data is documented under O. The assessment or diagnosis is written under A., And the plan of treatment is documented under P.
