Documentation Of Problem-Based Assessment Of The Gastrointes ✓ Solved

Documentation of problem based assessment of the gastrointestinal

Document a problem-based subjective and objective assessment of the gastrointestinal system. Identify abnormal findings. Use three sections: Subjective, Objective, and Actual or potential risk factors for the client based on the assessment findings with description or reason for selection of them. Format in Standard American English (correct grammar, punctuation, etc.). Resources: Chapter 5: SOAP Notes: The subjective and objective portion only Sullivan, D. D. (2012). Guide to clinical documentation. [E-Book]. Smith, L. S. (2001, September). Documentation do’s and don’ts. Nursing, 31 (9), 30.

Paper For Above Instructions

Introduction

Assessment of the gastrointestinal (GI) system is a pivotal component of patient care in nursing practice. A comprehensive understanding of the subjective and objective findings, along with potential risk factors, is essential for effective diagnosis and treatment plans. This paper aims to outline a problem-based assessment of the gastrointestinal system, identifying critical abnormal findings while adhering to the standard formatting as described in the guidelines.

Subjective Assessment

The subjective assessment of the gastrointestinal system must encompass detailed information about the patient's symptoms and relevant medical history. The primary components include biographic data, current medications, allergies, and a thorough symptom analysis using the PQRSTU approach, which stands for Provocation, Quality, Region, Severity, Timing, and Understanding.

For example, a 55-year-old female patient may report experiencing intermittent abdominal pain predominantly centered in the epigastric region. The patient describes the pain as a "burning" sensation (Quality), that worsens after eating fatty meals (Provocation), has a severity rating of 7 on a scale of 10 (Severity), and occurs mainly during the evenings (Timing). The patient denies any history of gastrointestinal illness or surgery and is currently taking omeprazole for acid reflux.

In addition, obtaining a complete medication history, including over-the-counter drugs, is essential as they may impact gastrointestinal function. Noting allergies, particularly to medications such as NSAIDs, is critical due to the potential for gastrointestinal bleeding or ulceration.

Objective Assessment

The objective assessment involves the clinical examination and diagnostic tests that support the findings from the subjective assessment. The physical examination should include inspection, palpation, percussion, and auscultation of the abdominal area.

For instance, during inspection, the abdomen could appear distended and tender to touch, particularly in the epigastric region. Palpation may reveal mild tenderness without rigidity or guarding, while bowel sounds auscultated could be described as normal in frequency. Laboratory tests such as a complete blood count (CBC) can be helpful; the presence of elevated white blood cell counts may indicate an inflammatory process, while low hemoglobin levels could suggest chronic blood loss (Mayo Clinic, 2023). Imaging studies like an abdominal ultrasound can assist in visualizing structural abnormalities, such as gallstones or inflammation.

Actual or Potential Risk Factors

The assessment should not only document current findings but also address actual and potential risk factors that could exacerbate the patient’s condition. For this case, two significant risk factors include:

• Obesity: The patient is noted to be overweight, which increases the risk of developing gastroesophageal reflux disease (GERD) and may contribute to abdominal pain due to increased intragastric pressure (National Institute of Diabetes and Digestive and Kidney Diseases, 2023).
• Dietary Habits: The patient’s frequent consumption of high-fat meals presents a potential risk factor for gallbladder disease and exacerbation of acid reflux symptoms. Education on dietary modifications is essential to ameliorate gastrointestinal issues (American Gastroenterological Association, 2023).

Conclusion

This documentation of the gastrointestinal assessment highlights the importance of thorough subjective and objective evaluations. Identifying abnormal findings and potential risks provides a framework for enhancing patient care and implementing individualized treatment plans. By utilizing the SOAP note format, healthcare providers can effectively communicate and document their assessment process.

References

• American Gastroenterological Association. (2023). Dietary management of GERD. Retrieved from [link]
• Mayo Clinic. (2023). Abdominal pain: Symptoms & causes. Retrieved from [link]
• National Institute of Diabetes and Digestive and Kidney Diseases. (2023). Obesity & gastrointestinal disorders. Retrieved from [link]
• Sullivan, D. D. (2012). Guide to clinical documentation. [E-Book].
• Smith, L. S. (2001, September). Documentation do’s and don’ts. Nursing, 31(9), 30.
• Jones, C. (2018). The importance of documentation in nursing practice. Journal of Nursing Care Quality, 33(2), 148-153.
• American Nurses Association. (2015). Nursing documentation standards. Retrieved from [link]
• World Health Organization. (2020). Gastrointestinal health and nutrition: Guidelines. Retrieved from [link]
• Black, B. P. (2020). Professional nursing: Concepts & patterns (7th ed.). Jones & Bartlett Learning.
• Coyle, M. E., & Pegion, K. (2021). Clinical assessment in nursing: A comprehensive guide. Nursing Standard, 35(8), 45-51.