Documentation of problem based assessment of the gastroin ✓ Solved

Title: 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.

Instructions:

Content: Use of three sections:

  • Subjective

  • Objective

  • Actual or potential risk factors for the client based on the assessment findings with description or reason for selection of them.

Format: 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]. Retrieved from > Smith, L. S. (2001, September). Documentation do’s and don’ts. Nursing, 31 (9), 30. Retrieved from

Paper For Above Instructions

The gastrointestinal (GI) system is a complex network that plays a critical role in digestion, absorption of nutrients, and elimination of waste. Accurate documentation of problem-based assessments is essential for effective patient care. This paper will present a subjective assessment, objective findings, and actual or potential risk factors based on a comprehensive evaluation of the GI system.

Subjective Assessment

When assessing the gastrointestinal system, gathering a detailed subjective history from the patient is vital. The subjective assessment includes the patient's biographical data such as age, gender, and medical history, particularly any history of gastrointestinal disorders. A patient may report symptoms such as abdominal pain, changes in bowel habits, nausea, vomiting, or weight loss. For instance, a 45-year-old female presents with complaints of abdominal discomfort, bloating, and irregular bowel patterns over the past month.

Supporting information includes the patient’s medication history, allergies, and lifestyle factors such as diet and exercise routines. In this specific case, the patient reports taking over-the-counter antacids but has no known drug allergies. A family history of gastrointestinal disease, such as irritable bowel syndrome (IBS) or colorectal cancer, may also influence the assessment outcomes.

The utilization of the PQRSTU mnemonic can structure the symptom's analysis effectively. Here, P (Provocation) refers to what exacerbates the pain; Q (Quality) describes the nature of the pain such as sharp or dull; R (Region/Radiation) identifies where the pain is located; S (Severity) rates the pain on a scale of 1 to 10; and T (Timing) notes when the discomfort occurs. Lastly, U (Understanding) encompasses what the patient believes might be causing their symptoms, assisting healthcare providers in understanding the patient's perspective on their health condition.

Objective Assessment

The objective assessment involves a thorough physical examination of the gastrointestinal system. Observations may include general appearance, abdominal contour, and auscultation of bowel sounds. The examination will reveal whether the abdomen is distended or tender, and palpation can help assess for masses or organomegaly. Vital signs should also be taken into account during this examination.

For instance, in this scenario, the patient’s abdomen may feel soft but slightly tender upon palpation in the lower quadrants. Bowel sounds are active in all four quadrants, which is a positive sign indicating an absence of obstruction. Any signs of jaundice, pallor, or unusual coloration may indicate underlying issues that warrant further evaluation.

Health professionals must be cautious about incorporating subjective data into the objective findings, ensuring they draw clear boundaries between the two. For example, although the patient reported elevated discomfort under specific conditions, care should be taken to document only the measurable signs observed during the assessment to maintain objectivity.

Actual or Potential Risk Factors

The assessment findings should lead to identifying actual or potential risk factors affecting the patient. In this case, the subjective and objective findings suggest several risk factors. Firstly, the patient's age and family history of gastrointestinal disorders may predispose her to similar issues. Additionally, her irregular bowel habits can indicate the potential for future GI complications, such as constipation or IBS, if not managed appropriately.

Inadequate dietary intake, especially with a lack of fiber, can further exacerbate GI issues, making it critical for the patient to maintain a balanced diet rich in fruits, vegetables, and whole grains. Moreover, lifestyle factors such as physical inactivity can contribute to poor gastrointestinal health and complicate existing issues.

The comprehensive assessment points toward a need for counseling around dietary and lifestyle changes to mitigate these risks. Health education about recognizing symptoms that require immediate medical attention is paramount in empowering the patient to participate actively in their health management.

Conclusion

In conclusion, thorough documentation of the problem-based assessment of the gastrointestinal system is paramount in identifying abnormal findings and promoting effective patient care. By synthesizing subjective and objective assessments into a holistic view, healthcare providers can pinpoint actual and potential risk factors, creating a foundation for successful treatment and health education strategies.

References

  • 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.

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  • Brooks, N. (2020). The importance of thorough documentation in nursing. Journal of Nursing Practice, 10(4), 123-130.