Download NRSE 4520 Module 5 Focused Exam Esther Parker (GRADED A) and more Assignments Nursing in PDF only on Docsity!
MOD 5: Focused exam: Abdominal Pain
SUBJECTIVE DATA
COLLECTION
CHIEF COMPLAINT
Established chief complaint Reports abdominal pain
Reports difficulty with bowel
movements
Do you have any abdominal
pain
Are you able to have a bowel
movement?
ORIENTATION
Asked about orientation Oriented to own person
Oriented to place
Oriented to situation
Oriented to time
Can you tell me your name?
Can you tell me where you
are?
What brought you here?
What time is it?
HISTORY OF PRESENTING
ILLNESS
Asked about onset of the
pain
Reports discomfort for the
past five days
Reports pain worsen
intensely 2-3 days ago
How long have you had
stomach pain?
Has the stomach pain
changed?
Asked about location of the
pain
Reports pain in lower
abdomen
Reports pain is not localized
Denies flank pain
Where is your discomfort
located?
Is the pain in a specific spot?
Do you have pain on your
side?
Asked about pain rating scale Reports current pain rating of
Reports pain at its lowest
Reports pain at its worst 8/
How would your rate your
pain from a scale of 0-10?
How would you rate your
pain at its lowest?
How would you rate your
pain at its worst?
Asked about characteristics
of the pain
Describes pain as dull
Describes pain as cramping
Describes pain as constant
Describe pain as fluctuating
in severity
Can you describe your pain?
Can you describe your pain?
Is your pain constant?
Does your pain fluctuate?
Asked about non-
pharmacological relieving
factors
Reports that resting helps
relieve pain
Reports drinking warm water
to relieve pain was ineffective
What relieves your pain
besides medication?
What relieves your pain
besides medication?
Asked about pharmacological
relieving factors
Denies taking pain
medication
Have you taken medication
for your stomach pain?
Denies taking laxatives Have you taken laxatives?
Asked about aggravating
factors
Reports pain aggravated by
eating
Reports pain is aggravated by
physical activity
Does eating aggravate the
pain?
Does physical activity
aggravate the pain?
Asked about impact of pain
on daily life
Reports recent difficulty
participating in usual
activities
Reports low energy
How has your illness affected
your daily life?
Have you had low energy?
Followed up on constipation Reports current constipation
Reports constipation all of
last 5 days
Are you constipated right
now?
For how long you have been
constipated?
Asked about diarrhea Reports recent diarrhea Have you had diarrhea
recently?
Followed up on diarrhea Reports diarrhea about six
months ago
Reports diarrhea had a
sudden onset
Reports diarrhea lasted one
day
How long ago did you have
diarrhea?
Did the diarrhea happen
suddenly?
How long did your diarrhea
last?
Asked about substance in
stool
Denies mucus in stool
Denies blood in stool
Has there been mucus in
your stool?
Has there been blood in your
stool?
Asked about urination Reports slightly decreased in
frequency of urination
Reports darker urine recently
Denies blood in urine
Have you had changes in the
frequency of your urination?
Has your urine been darker
recently?
Is there blood in your urine?
Asked about fluid intake Reports decreased thirst
Reports decreased fluid
intake for the last few days
Typically fluid intake is 1-
glasses of water a day
Denies drinking caffeinated
drinks such as coffee or soda
Have you been thirster
lately?
Have you had changes in
your fluid intake?
How many glasses of water
do your drink daily?
Do you drink caffeinated
beverage?
PAST MEDICAL HISTORY
Asked about history of
constipation
Denies history of
constipation
Are you typically
constipated?
Asked about typical bowel
movements
Reports typically having a
bowel movement almost
How many bowel movements
do you typically have in a
Denies difficulty bathing
Denies difficulty transferring
in and out of chairs
bathing?
Do you have difficulty
transferring in and out of
chairs?
Asked about diet Reports last meal was toast
at breakfast
Reports typically eating 3
meals
Denies eating snacks
regularly
Reports typical breakfast is
toast
Reports typical lunch is soup
Reports sometimes skipping
lunch due to low appetite
Reports typical dinner is
chicken or fish with rice
What was your last meal?
How many meals do you
typically eat per day?
Do you typically eat snacks?
What do you usually eat for
breakfast?
What do you usually eat for
lunch?
What do you usually eat for
lunch?
What do you usually eat for
dinner?
Asked about fiver intake Denies taking fiber
supplements
Denies efforts to incorporate
fiber in her diet
Reports eating a vegetable
every 1 or 2 days
Reports eating fruits every 3
or 4 days
Do you take fiber
supplements?
Do you think you get enough
fiber?
What source of fiber do you
eat?
Do you eat fruits?
Asked about typical activity
level
Reports typically high level of
mobility and independence
Reports typically having a
moderate activity level
Do you stay active?
What is your typical activity
level?
Asked about substance use Denies illicit drug use
Denies cigarette smoking
Reports low alcohol
consumption
Do you use illicit drugs?
Do you smoke cigarettes?
Do you drink alcohol?
Followed-up on alcohol
consumption
Reports drinking 1 night a
week
Reports 1 drink per sitting
Reports typical drink is white
wine
How many nights a week do
you drink alcohol?
How many alcoholic drinks
do you drink a month?
What alcoholic drink do you
typically drink?
Asked about psychosocial
history
Reports living with her
daughter
Reports strong familial
Do you live with anyone?
Who can you go for support?
support system
Denies recent travel Have you traveled recently?
Asked about experience of
abuse
Denies being physically
abused
Denies being sexually abused
Denies being emotionally
abused
Denies being financially
abused
Denies being verbally abused
Have you experienced any
physical abuse?
Have you experience any
sexual abuse?
Have you experience
emotional abuse?
Have you experienced any
financial abuse?
Have you experience any
verbal abuse?
REVIEW OF SYSTEMS
Asked about constitutional
health
Denies recent weight
changes
Denies recent fever
Denies chills
Denies night sweats
Denies swelling
Reports short-term feeling of
exhaustion
Denies sleep issues
Have you had recent changes
in your weight?
Have you had recent fever?
Have you had chills?
Have you had night sweats?
Have you had swelling?
Do you have fatigue?
Do you have sleep issue?
Asked about history of
gastrointestinal disorders
Denies history of GERD or
ulcer
Denies history of appendicitis
Denies history of stomach
Cancer
Denies history of liver disease
Do you have history of
heartburn?
Do you have a history of
appendicitis?
Do you have a history of
stomach cancer?
Do you have a history of liver
disease?
Asked about cardiovascular
health
Denies palpitations
Denies chest discomfort
Denies racing heartbeat
Do you have palpitations?
Do you have chest
discomfort?
Does your heart race?
Asked about throat irritation Denies sore throat Do you have a sore throat?
Asked about respiratory
health
Denies coughing
Denies difficulty swallowing
Denies difficulty breathing
Do you have a cough?
Do you have difficulty
swallowing?
Do you have difficulty
breathing?
Asked about additional
review of systems for
gastrointestinal
Reports bloating
Reports slight increase in gas
Do you feel bloated?
Do you have an increase in
gas?
Inspected nasal mucosa
1 of 1 point Appearance (1/1 point) Moist and pink
Inspected mouth
1 of 1 point Oral Mucosa (1/1 point) Moist and pink
Inspected abdomen
0.67 of 1 point Symmetry (1/3 point) Symmetric Contour (1/3 point) Flat Appearance (No point) Scarring
Inspected for edema in lower extremities
1 of 1 point Right: Edema (1/4 point) No edema Right: Severity Of Edema (1/4 point) No edema Left: Edema (1/4 point) No edema Left: Severity Of Edema (1/4 point)
No edema
Auscultated heart sounds
0.5 of 1 point Heart Sounds (No point) S1, S2, S3, and S4 audible Extra Heart Sounds (1/2 point) No extra sounds
Auscultated breath sounds
1 of 1 point Breath Sounds (1/3 point) Present in all areas Adventitious Sounds (1/3 point) No adventitious sounds Location (1/3 point) All areas clear
Auscultated abdominal aorta
Sound (1/1 point) No bruit
Auscultated bowel sounds
1 of 1 point Bowel Sounds (1/2 point) Normoactive Location Of Non Normoactive Bowel Sounds (1/2 point)
Percussed spleen
1 of 1 point Spleen (1/1 point) Tympany
Percussed liver
1 of 1 point Liver Span (1/1 point) Between 6 and 12 cm
Palpated abdomen - light
0.67 of 1 point Tenderness (1/3 point) Tenderness reported Location Of Tenderness (1/3 point) Left lower quadrant Observations (No point) Guarding Distension
Palpated abdomen - deep
1 of 1 point Presence Of Unexpected Mass (1/2 point) Palpable mass Location Of Mass (1/2 point) Left lower quadrant
Palpated liver
1 of 1 point
Detection (1/1 point) Palpable
Palpated spleen
1 of 1 point Detection (1/1 point) Not palpable
Palpated bladder
1 of 1 point Detection (1/1 point) Not palpable
Palpated kidneys
1 of 1 point Right (1/2 point) Not palpable Left (1/2 point) Not palpable
Tested skin turgor
1 of 1 point Observations (1/1 point) No tenting
EDUCATION & EMPATHY
1. Pain & Constipation
Description: Ms. Park describes the symptoms that have been bothering her. Model Statement: "I’m sorry you’re having these symptoms; it sounds like you’re under great discomfort. It’s good that you came in today so we can discuss how to
have the quickest, most widespread impact on the Ms. Park's condition, including on her abdominal discomfort.
Etiologies
Student Response Model Answer Explanation Points Earned deficient fluid intake deficient fluid intake The amount of fluid and fiber Ms. Park reports in her diet is insufficient for regular gastrointestinal functioning. Other options listed are not appropriate etiologies for Ms. Park's case. 2 out of 2 deficient fluid intake deficient fiber intake The amount of fluid and fiber Ms. Park reports in her diet is insufficient for regular gastrointestinal functioning. Other options listed are not appropriate etiologies for Ms. Park's case. 0 out of 2
Signs & symptoms
Student Response Model Answer Explanation Points Earned palpable abdominal mass palpable abdominal mass Ms. Park presents with abdominal tenderness and discomfort, defecation fewer than two times per week, distended abdomen, generalized fatigue, and a palpable abdominal mass. 2 out of 2 generalized fatigue generalized fatigue Ms. Park presents with abdominal tenderness and discomfort, defecation fewer than two times per week, distended abdomen, generalized fatigue, and a palpable abdominal mass. 2 out of 2 abdominal tenderness abdominal tenderness Ms. Park presents with abdominal tenderness and discomfort, defecation fewer than two times per week, distended abdomen, generalized 2 out of 2
fatigue, and a palpable abdominal mass. distended abdomen distended abdomen Ms. Park presents with abdominal tenderness and discomfort, defecation fewer than two times per week, distended abdomen, generalized fatigue, and a palpable abdominal mass. 2 out of 2 defecation fewer than two times per week defecation fewer than two times per week Ms. Park presents with abdominal tenderness and discomfort, defecation fewer than two times per week, distended abdomen, generalized fatigue, and a palpable abdominal mass. 2 out of 2 abdominal discomfort Ms. Park presents with abdominal tenderness and discomfort, defecation fewer than two times per week, distended abdomen, generalized fatigue, and a palpable abdominal mass. 0 out of 2
Self Assessment
Prompt Student Response Model Answer Explanation Why should constipation be prioritized as the most important diagnosis for Esther Park? Constipation should be prioritzed as the most important diagnosis for Esther Park because she states she has not had a bowel moviement in about 5 days. She is also in pain from the discomfort, and with her assessment she has a palpable mass on her left lower quadrant. Constipation is the highest priority nursing diagnosis because it is the root cause of Ms. Park's abdominal discomfort. Treating her constipation will lead to improvement of all of her signs and symptoms, resulting in the greatest improvement to her overall well-being. When multiple aspects of a patient's condition require treatment, prioritize the diagnosis that has the greatest impact on the patient's well- being when treated, and is treatable within a reasonable timeframe.
Planning
Discuss the importance of fluid and fiber intake with patient Tell patient to leave any outputs unflushed for examination The five interventions prioritized for Ms. Park will all directly lead to a bowel movement and keep Ms. Park safe and informed throughout the process. Interventions such as education, while beneficial for the patient's long-term health, should not be prioritized above relieving her acute constipation. 0 out of 2 Provide patient with 1 cup bran cereal and advise to eat over the next hour Have patient ambulate the length of the hallway with patient care tech assistance The five interventions prioritized for Ms. Park will all directly lead to a bowel movement and keep Ms. Park safe and informed throughout the process. Interventions such as education, while beneficial for the patient's long-term health, should not be prioritized above relieving her acute constipation. 0 out of 2 Provide patient with 500ml of fluid and advise to drink over the next 2 hours Provide patient with 500ml of fluid and advise to drink over the next 2 hours The five interventions prioritized for Ms. Park will all directly lead to a bowel movement and keep Ms. Park safe and informed throughout the process. Interventions such as education, while beneficial for the patient's long-term health, should not be prioritized above relieving her acute constipation. 2 out of 2 Intervention Rationale Your answer is not automatically evaluated by the simulation, but may be reviewed by your instructor. Prompt Student Response Model Answer Explanation In 1 or 2 sentences, explain how your selected interventions work to Since Pt. is constipated we would wanna relieve the constipation by giving patient a Given the time constraints, an enema is the appropriate intervention to induce a bowel movement in Ms. Park. The other It is important to assure the interventions you carry out are relevant and therapeutic for this
accomplish your goal. stool softner or a laxative to cleanse the bowel. We would also want to encourage fluids and fiber and interventions will help aid in a bowel movement, as well as keep Ms. Park safe, educated, and hydrated during the process. particular patient so as not to waste time or put the patient's health at risk. Data Collections Student Response Model Answer Explanation Points Earne d Ask about pain rating, abdominal cramping, nausea, and dizziness (subjective) Ask about pain rating, abdominal cramping, nausea, and dizziness (subjective) Some of the appropriate data collections provide information on your short-term goal, in this case the production of a complete bowel elimination in Ms. Park. Other data collections allow you to assess the patient's current status and any side effects, dehydration, or lingering pain she may have and require treatment for. 2 out of 2 Assess change in knowledge around fiber and fluid intake (subjective) Ask about patient outputs, presence of stool, and sense of constipation (subjective) Some of the appropriate data collections provide information on your short-term goal, in this case the production of a complete bowel elimination in Ms. Park. Other data collections allow you to assess the patient's current status and any side effects, dehydration, or lingering pain she may have and require treatment for. 0 out of 2 Evaluate any stool for amount and qualities (objective) Evaluate any stool for amount and qualities (objective) Some of the appropriate data collections provide information on your short-term goal, in this case the production of a complete bowel elimination in Ms. Park. 2 out of 2
cleanse your bowel since you are constipated. getting enough fluids or enough fiber in your diet. improvement. Explain your goal for Ms. Park and the interventions and data collections through which you will achieve it. Our goal is have 1 or 2 bowel movement to clear your bowel In order to relieve your constipation, the goal is for you to have a bowel movement, so that your pain and abdominal discomfort are relieved. I'm going to give you an enema, which should be quick and effective. I will also have you walk around to help get your bowels moving. Throughout the process, I'll keep you hydrated and make sure that you're safe and comfortable. I will evaluate you for dehydration and side effects of the enema, and ask about your outputs. We're going to do everything we can to get your bowels moving so you can feel some relief! You should communicate the care plan to the patient, allowing them to have involvement and agency in their own healthcare. Explicitly ask for Ms. Park's consent to the care plan. Would it be okay if we proceed with the enema? Do I have your consent to move forward with these interventions? A patient must consent to all interventions in their care plan. Disagreements are opportunities to provide further patient education and to consider alternative options. Inform Ms. Park that an enema may cause side effects, such as Side effects of an enema Ms. Park are abdominal cramping, nausea, dizziness As a result of the enema, it's possible that you could feel cramping, nausea, dizziness, and diarrhea. If you notice Communicate potential side effects to a patient, so she is aware of the risks
abdominal cramping, nausea, dizziness, and diarrhea. and diarrhea anything like this, don't hesitate to let me know. and feels comfortable expressing any health changes.
Intervention & Evaluation
Student Response Model Answer Explanation Points Earned Fully Fully Ms. Park's goal has been fully achieved, because she has had a bowel movement, reporting a 0/ pain rating and feeling "completely relieved of constipation." These statements are supported by the size and consistency of her stool. 10 out of 10
Intervention & Evaluation Rationale
Prompt Student Response Model Answer Explanation Did you achieve your goal of inducing a bowel movement that relieved the patient's constipation, resulting in the patient reporting relief and diminished pain? I chose an enema because it has been more than 3 days since she last had a bowel movement and the build up of in her colon is not ideal; therefore, a quick release can assist her abdominal pain some relief. Fluid intake is also good since she has not had much to drink and her not flushing is a way for us to keep track of her urine and ambulating also will help move the bowels along. The goal of relieving Ms. Park's constipation has been fully achieved because the enema, along with the other interventions, induced a bowel movement. She stated that she feels relieved and empty, which shows that the patient's experience of signs and symptoms has greatly diminished. Most importantly, her discomfort has gone away. She rated her current pain as a 0 out of 10. The objective data that was gathered also supports this evaluation, as the characteristics of the stool show that she has had a complete bowel elimination. Multiple pieces of data, both subjective and objective, are required to make a credible and careful assessment.
