Assessment of the Abdomen and Gastrointestinal System Comprehensive Nursing Paper Example
The purpose of this paper is to; (1) analyze and provide additional information to the subjective and objective of the SOAP note on abdominal pain/diarrhea assessment. (2) Determine whether the assessment provided is supported by subjective and objective information provided. (3) Provide diagnostic tests appropriate for abdominal pain/diarrhea assessment. (4) Provide a rationale for accepting or rejecting the provided diagnosis, including differential diagnosis.(Assessment of the Abdomen and Gastrointestinal System Comprehensive Nursing Paper Example)
Abdominal pain constitutes a subjective feeling of abdominal discomfort arising from various factors. In contrast, diarrhea refers to the subjective and objective experience of loose watery stool caused by several underlying infections and acute or chronic conditions. SOAP note provides a methodology of documenting and communicating objective, subjective, and laboratory assessment that can be used for primary and differential diagnosis. This way, it is crucial to complete a comprehensive assessment to determine the fundamental factors contributing to the patient’s symptoms.(Assessment of the Abdomen and Gastrointestinal System Comprehensive Nursing Paper Example)
Analyze the subjective portion of the note. List additional information that should be included in the documentation.
Subjective information on a patient’s history of pain is crucial in determining possible differential diagnoses when assessing a patient presenting generalized abdominal pain (Ball et al., 2015). In this case, the focused question should reveal additional clinical information on (1) the patient’s history of pain, including onset and characteristics. For instance, the information should indicate whether the pain was gradual or sudden, cramping or colicky and whether the pain causes sleeplessness. (2) Location of the pain, i.e., what side of the abdomen is painful? Does the pain radiate? (3) History of diet including changes in eating patterns, loss of appetite, intake of high carbohydrate fluids, lactose intolerance, hypersensitivity to milk/soy protein, or celiac sprue. (4) Information on vomiting, fever, and diarrhea status. (5) History of surgery since surgery can cause adhesion of organs leading to abdominal pain (Ball et al., 2019). (6) General information, e.g., weight loss, i.e., does the patient have weight loss? If so, is it involuntary or premeditated?(Assessment of the Abdomen and Gastrointestinal System Comprehensive Nursing Paper Example)
Analyze the objective portion of the note. List additional information that should be included in the documentation.
Objective information is crucial in ascertaining subjective data as t involves measuring facts and vital signs. In this case, additional information is needed to substantiate the patient’s perception of his illness on two aspects. First, there is a need for general information on the patient’s restlessness, type of pain, body position, and general appearance. The second information needed for this section regards the vital signs. These include throat observation for presence or absence of exudate, erythema, or anterior cervical adenopathy. Other relevant information consists of the characteristics and softness of abdominal musculature, abdominal skin coloring, abdominal distention, and palpations. Further, information on auscultate bowel stones, tones, guarding, and tenderness of percussing. Lastly, information on the patient’s hydration status and palpation of the groin, masses, and hernias.(Assessment of the Abdomen and Gastrointestinal System Comprehensive Nursing Paper Example)
Does subjective and objective information support the assessment? Why or why not?
The assessments are supported by subjective and objective information. The first assessment, i.e., Left lower quadrant pain, is characterized by, among other symptoms, abdominal cramping, diarrhea, nausea, hyperactive bowel sounds, and EtOH consumption (Ball et al., 2019) as pointed by the patient’s objective and subjective information. However, limited data points to LLQ pain, considering the patient complained of generalized abdominal pain. As discussed in the first two sections of this essay, additional information on the subjective and objective note would reveal the patient’s abdominal pain location and other characteristics. The patient’s past medical history of Amlodipine and Metformin has been associated with abdominal pain (Devasahayam et al., 2012; Siavash et al., 2017). In the second assessment, gastroenteritis is characterized by abdominal pain, hyperactive bowel sounds, nausea, vomiting, diarrhea, and fever (Ball et al., 2019), as pointed by the patient’s objective and subjective information.(Assessment of the Abdomen and Gastrointestinal System Comprehensive Nursing Paper Example)
What diagnostic tests would be appropriate for this case, and how would the results be used to make a diagnosis?
- Fecal Leukocytes
The test diagnoses bacterial diarrhea since it shows the presence of bacteria in the intestinal wall. This information is crucial in determining whether the patient has an inflammatory diarrhoeal disease.(Assessment of the Abdomen and Gastrointestinal System Comprehensive Nursing Paper Example)
- Fecal immunochemical tests (FIT)
FIT is done to determine a specific amount of blood in the feces, using antigen to hemoglobin reaction. Most bowel abnormalities cause bleeding. Positive FIT indicates bowel abnormality and can direct further exhaustive investigation. Significantly, vitamins or food do not affect the FIT test.(Assessment of the Abdomen and Gastrointestinal System Comprehensive Nursing Paper Example)
- Stool Testing
Stool testing is used to detect the presence of common parasites and Giardia in stool samples. Thus, it is crucial for patients with abdominal pain and diarrhea. The test uses fresh stool from which presence of common bacteria. On the contrary, the Giardia antigen test is used to detect the level of antigen 65 used for detecting Giardiasis.(Assessment of the Abdomen and Gastrointestinal System Comprehensive Nursing Paper Example)
- Abdominal Ultrasound
It helps in evaluating the cause of abdominal pain. Abdominal ultrasound can confirm hernia or fecal loading in patients whose feces was not palpable. In this case, palpation is a significant sign of gastroenteritis. Besides, abdominal ultrasound shows the size of organs, and this information can be used to determine inflammation, e.g., appendix inflammation can indicate appendicitis.(Assessment of the Abdomen and Gastrointestinal System Comprehensive Nursing Paper Example)
- Computed Tomography and Magnetic Resonance Imaging
CT scan shows abnormalities of organs and blood clots. Thus, it may help detect specific rare causes of acute diarrhea such as inflammatory bowel disease. Equally, an MRI scan shows blood flow, organ function, and abnormalities. Thus, it can be used to diagnose abdominal obstruction, appendicitis, and retroperitoneal bleeding.(Assessment of the Abdomen and Gastrointestinal System Comprehensive Nursing Paper Example)
Would you reject/accept the current diagnosis? Why or why not? Identify three possible conditions that may be considered as a differential diagnosis for this patient. Explain your reasoning using three different references from current evidence-based literature.
The subjective and mainly objective points to gastroenteritis other than the left lower quadrant pain. This way, I would partly reject LLQ diagnosis and accept gastroenteritis as supported by the subjective and objective information on symptoms such as fever, diarrhea, nausea, vomiting, abdominal pain, soft, hyperactive bowel sounds, history of gastrointestinal bleeding, and EtOH consumption. Other possible differential diagnoses include:(Assessment of the Abdomen and Gastrointestinal System Comprehensive Nursing Paper Example)
- Food poisoning with enterotoxin Escherichia coli
E.coli infection is felt after eight to eighteen hours following ingestion of contaminated food or water and lasts between 24 and 48 hours (Ball et al., 2019). According to Gomes et al. (2016), food poisoning caused by E.coli ischaracterized by moderate bloodless diarrhea, cramping, and abdominal pain. All of these symptoms are experienced by the patient in this case. (Assessment of the Abdomen and Gastrointestinal System Comprehensive Nursing Paper Example)
Ureterolithiasis symptoms include progression from a colicky to constant pain in the lower abdomen (Ball et al., 2019). Besides, patients experience nausea, vomiting, abdominal distention, chills, and fever (Glazer et al., 2020). Other symptoms include increased urination frequency. These symptoms are experienced by the patient in this case, save for chills.(Assessment of the Abdomen and Gastrointestinal System Comprehensive Nursing Paper Example)
- Irritable bowel syndrome
Symptoms for Irritable bowel symptoms include hypogastric pain with infrequent duration (Ball et al., 2019). Patients experience the sudden urge for bowel movement, loose and frequent stools, and abdominal pain (Chey et al., 2015). All of these symptoms are experienced by the patient in this case.(Assessment of the Abdomen and Gastrointestinal System Comprehensive Nursing Paper Example)
Comprehensive clinical assessment is crucial for the diagnosis of common clinical symptoms. This paper provides crucial information needed in the objective, subjective sections of abdominal pain and diarrhea assessment SOAP. Besides, the paper provides an appropriate differential diagnosis for the symptoms shown by the patient. This way, the paper underscores its primary purpose of completing abdominal pain/diarrhea SOAP note.(Assessment of the Abdomen and Gastrointestinal System Comprehensive Nursing Paper Example)
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to physical examination: An interprofessional approach (9th Ed.). St. Louis, MO: Elsevier Mosby.
Chey, W. D., Kurlander, J., & Eswaran, S. (2015). Irritable bowel syndrome: a clinical review. Jama, 313(9), 949-958. https://doi.10.1001/jama.2015.0954
Devasahayam, J., Pillai, U., & Uppaluri, C. (2012). Acute severe intestinal obstruction secondary to amlodipine toxicity. QJM: An International Journal of Medicine, 105(5), 467-469. https://doi.org/10.1093/qjmed/hcr052
Glazer, K., Brea, I. J., & Vaitla, P. (2020). Ureterolithiasis. StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK560674/
Gomes, T. A., Elias, W. P., Scaletsky, I. C., Guth, B. E., Rodrigues, J. F., Piazza, R. M., … & Martinez, M. B. (2016). Diarrheagenic Escherichia coli. Brazilian Journal of Microbiology, 47, 3-30. https://doi.org/10.1016/j.bjm.2016.10.015
Siavash, M., Tabbakhian, M., Sabzghabaee, A. M., & Razavi, N. (2017). The severity of gastrointestinal side effects of metformin tablet compared to metformin capsule in type 2 diabetes mellitus patients. Journal of research in pharmacy practice, 6(2), 73. https://doi.10.4103/jrpp.JRPP_17_2