Documentation of problem based assessment of the gastrointestinal system.
Purpose of Assignment:
Learning the required components of documenting a problem based subjective and objective assessment of gastrointestinal system. Identify abnormal findings.
Prioritize appropriate assessment techniques for the gastrointestinal, breasts, and genitourinary systems.
Content: Use of three sections:
· Actual or potential risk factors for the client based on the assessment findings with description or reason for selection of them.
· Standard American English (correct grammar, punctuation, etc.)
· Clients Presentation: ( Your client can make up whatever they want. They can be as dramatic. Have fun with it!)
· Subjective Data (4 points): (Review History questions in power point and on page 534-535 of text.)
· Objective Data (4 points):
· Inspection: What is the shape and size of the abdomen? Any masses or pulsations upon inspection? Skin smooth? Striae, scars, lesions?
· Auscultation: Bowel Sounds Present in all 4 quadrants? Hypoactive, Normoactive, etc. Any bruits upon auscultation?
· Percussion: Tympany in all 4 quadrants?
· Palpation: Abdomen soft, firm? Any enlarged organs? Masses? Tenderness?
· Any other objective data you found important to document?
· Describe 2 Actual/Potential Risk Factors ( 2 points):