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NURS 4520 Esther Park Shadow Health Abdominal Assessment

NURS 4520 Esther Park Shadow Health Abdominal Assessment

NURS 4520 Esther Park Shadow Health Abdominal Assessment

Ms. Esther Park 1s a /   -year-old woman who comes to the clinic complaining of abdominal pain. She reports that the pain isn’t severe, but that her daughter was concerned and brought her in. It is very important to determine whether or not the situation is an emergency and that the underlying cause of Esther’s discomfort. Be sure to inquire about a variety of psychosocial factors related to the GI system, including diet, toilet habits, immunizations, recent travel, etc.

This case study will offer you the opportunity to take a complete surgical, reproductive, and current sexual history. During her physical examination, take particular note as to where Mrs. Park verbalizes pain during palpation so that you may synthesize verbal and non-verbal cues. Be sure to apply the supportive information learned in this week’s concept lab to your critical thinking process in this case study.

Scattered dullness in LLQ during percussion is suggestive of feces in the colon; otherwise, her abdomen is tympanic. Her abdomen is soft to palpation; mild guarding and oblong mass suggesting feces were discovered in LLQ. No CVA tenderness; liver span 7 cm @ MCL; no splenic dullness.

Digital rectal exam revealed a fecal mass in the rectal vault. No abnormalities were noted during the pelvic exam, so pelvic inflammatory disease is not suspected. Ms. Park’s urinalysis was normal, which rules out a urinary tract infection. No signs of dehydration. NURS 4520 Esther Park Shadow Health Abdominal Assessment

NURS 4520 Esther Park Shadow Health Abdominal Assessment

Explanation:

From the physical exam alone, I can already conclude the patient will need a manual disimpaction. The physical examination also suggests that constipation is an issue. The LLQ dullness is suggestive of feces. As we know, the LLQ is where the descending and sigmoid colon are located.

The sigmoid colon obviously leads to the rectum which is where a fecal mass is identified. We know there is no hepatomegaly, the spleen is WNL, UA is negative, etc. NURS 4520 Esther Park Shadow Health Abdominal Assessment

It seems as though the primary cause for the abdominal pain is the fecal impaction. I would also say this is emergent, because there is mild guarding on physical examination. Even though it is just mild, it still suggests inflammation and inflammation suggests infection.

The patient should be sent to the ER, for routine labs (CBC, CMP, Lactic, etc) and imaging. NURS 4520 Esther Park Shadow Health Abdominal Assessment

Objective Data Collection: 21 of 21 (100%)

Subjective Data Collection

Objective Data Collection

  • Correct
  • Partially correct
  • Incorrect
  • Missed

Education & Empathy Documentation

Inspected head and face 1 of  1 point

Care Plan

Skull Symmetry (1/3 point)
  • Symmetric
  • Asymmetric
Facial Feature Symmetry (1/3 point) NURS 4520 Esther Park Shadow Health Abdominal Assessment
  • Symmetric
  • Asymmetric
Appearance (1/3 point)
  • No visible abnormal findings Flushed appearance
  • Rash or lesion
  • Skin growths (freckles, moles, or birth mark) Excessive hair growth
  • Evidence of skin trauma (scar, laceration, or bruising)

Inspected nasal mucosa 1 of 1 point

Inspected mouth 1 of 1 point

Oral Mucosa (1/1 point)
  • Moist and pink
  • Dry appearance
  • Redness

Inspected abdomen 1 of 1 point

Symmetry (1/3 point)
  • Symmetric
  • Asymmetric
Contour (1/3 point) NURS 4520 Esther Park Shadow Health Abdominal Assessment
  • Flat
  • Rounded
  • Protuberant
  • Hollowed
Appearance (1/3 point)
  • No visible abnormal findings
  • Rash
  • Striae

https://www.coursehero.com/file/54630935B/Euslgthinegr-aPraoruknsd-Aubmdboilmicuinsal-Pain-ObjectiveData-Shadow-Healthpdf/

  • Distension NURS 4520 Esther Park Shadow Health Abdominal Assessment
  • Visible masses (warts, cysts, or tumors) Freckles, birthmark, or discoloration
  • Excessive hair growth
  • Scarring
  • Laceration, lesion, or wound Bruising
  • Redness
  • Jaundice
  • Prominent veins

Inspected for edema in lower extremities 1 of 1 point

Right: Edema (1/4 point) NURS 4520- Esther Park Shadow Health Abdominal Assessment
  • No edema
  • Pitting
  • Non-pitting
Right: Severity Of Edema (1/4 point) NURS 4520 Esther Park Shadow Health Abdominal Assessment
  • No edema
  • 1+ Slight pitting
  • 2+ Deeper pit, disappears in 10 to 15 seconds
  • 3+ Noticeably deep pit that lasts more than a minute 4+ Very deep pit that lasts 2 to 5 minutes
Left: Edema (1/4 point)
  • No edema
  • Pitting
  • Non-pitting
Left: Severity Of Edema (1/4 point) NURS 4520 Esther Park Shadow Health Abdominal Assessment
  • No edema
  • 1+ Slight pitting
  • 2+ Deeper pit, disappears in 10 to 15 seconds
  • 3+ Noticeably deep pit that lasts more than a minute 4+ Very deep pit that lasts 2 to 5 minutes

Auscultated heart sounds 1 of 1 point

Heart Sounds (1/2 point)
  • S1 and S2 audible
  • S1, S2, and S3 audible S1, S2, and S4 audible
  • S1, S2, S3, and S4 audible
Extra Heart Sounds (1/2 point)
  • No extra sounds
  • Gallops
  • Murmur
  • Friction rub
  • Valve clicks

Auscultated breath sounds    NURS 4520 Esther Park Shadow Health Abdominal Assessment  1 of 1 point

Breath Sounds (1/3 point)
  • Present in all areas
  • Diminished in some areas
  • Absent in some areas
Adventitious Sounds (1/3 point)
  • No adventitious sounds
  • Wheezing
  • Fine crackles Stridor
  • Rhonchi Rales
Location (1/3 point)
  • All areas clear
  • Adventitious sounds in anterior right upper lobe Adventitious sounds in anterior right middle lobe
  • Adventitious sounds in anterior right lower lobe Adventitious sounds in anterior left upper lobe
  • Adventitious sounds in anterior left lower lobe
  • Adventitious sounds in posterior right upper lobe Adventitious sounds in posterior right lower lobe
  • Adventitious sounds in posterior left upper lobe Adventitious sounds in posterior left lower lob NURS 4520 Esther Park Shadow Health Abdominal Assessment

Auscultated abdominal aorta 1 of 1 point

https://www.coursehero.com/file/54630935/Esther-Parks-Abdominal-Pain-ObjectiveData-Shadow-Healthpdf/

Sound (1/1 point)
  • No bruit
  • Bruit

Auscultated bowel sounds                                                                                                                    1 of 1 point

Bowel Sounds (1/2 point) NURS 4520- Esther Park Shadow Health Abdominal Assessment
  • Absent
  • Hypoactive
  • Normoactive
  • Hyperactive
Location Of Non Normoactive Bowel Sounds (1/2 point)
  • All quadrants normoactive
  • Right upper quadrant NURS 4520 Esther Park Shadow Health Abdominal Assessment
  • Right lower quadrant
  • Left upper quadrant
  • Left lower quadrant

Auscultated abdominal arteries 1 of 1 point

Right: Renal (1/6 point)
  • No bruit
  • Bruit
Right: Iliac (1/6 point)
  • No bruit
  • Bruit
Right: Femoral (1/6 point)
  • No bruit
  • Bruit
Left: Renal (1/6 point)
  • No bruit
  • Bruit
Left: Iliac (1/6 point)
  • No bruit
  • Bruit
Left: Femoral (1/6 point) NURS 4520 Esther Park Shadow Health Abdominal Assessment
  • No bruit
  • Bruit

Percussed abdomen                                                                                                                    1 of 1 point

Observations (1/1 point)
  • All areas generally tympanic
  • Some areas dull, some tympanic
  • Some areas resonant

Percussed CVA tenderness 1 of 1 point

Patient Reaction (1/1 point)
  • Did not react
  • Pain reaction

Percussed spleen 1 of 1 point

Spleen (1/1 point) NURS 4520- Esther Park Shadow Health Abdominal Assessment

  • Tympany
  • Dullness

Percussed liver 1 of 1 point

Liver Span (1/1 point)
  • Smaller than 6 cm
  • Between 6 and 12 cm
  • Greater than 12 cm

Palpated  abdomen – light  NURS 4520 Esther Park Shadow Health Abdominal Assessment 1 of 1 point

Tenderness (1/3 point)
Location Of Tenderness (1/3 point)

https://www.coursehero.com/file/54630935N/Eosnteherer-pPoarrtekds-Abdominal-Pain-ObjectiveData-Shadow-Healthpdf/

  • No quadrants tender
  • Tenderness reported
  • Right upper quadrant
  • Right lower quadrant
  • Left upper quadrant
  • Left lower quadrant
Observations (1/3 point)
  • No additional observations
  • Masses
  • Guarding
  • Distension

Palpated abdomen – deep NURS 4520 Esther Park Shadow Health Abdominal Assessment 1 of 1 point

Presence Of Unexpected Mass (1/2 point)
  • No palpable mass
  • Palpable mass
Location Of Mass (1/2 point)
  • No palpable mass
  • Right upper quadrant
  • Right lower quadrant
  • Left upper quadrant
  • Left lower quadrant
  • Around umbilicus
Palpated liver 1 of 1 point
Detection (1/1 point)
  • Not palpable
  • Palpable

Palpated spleen  NURS 4520 Esther Park Shadow Health Abdominal Assessment 1 of 1 point

Detection (1/1 point)
  • Not palpable
  • Palpable

Palpated bladder NURS 4520 Esther Park Shadow Health Abdominal Assessment 1 of 1 point

Detection (1/1 point)
  • Not palpable
  • Palpable

Palpated kidneys NURS 4520 Esther Park Shadow Health Abdominal Assessment 1 of 1 point

Right (1/2 point)
  • Palpable
  • Not palpable
Left (1/2 point)
  • Palpable
  • Not palpable
Tested skin turgor 1 of 1 point
Observations (1/1 point)
  • No tenting
  • Tenting

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