Esther Park Shadow Health NR 509 Abdominal Pain Education and Empathy/Abdominal Pain Documentation S by welldoneassistant

12/10/2018

Abdominal Pain Physical Assessment Assignment | Completed | Shadow Health

Abdominal Pain Physical Assessment Assignment Results | Completed Advanced Health Assessment - Chamberlain, NR509-October-2018 Return to Assignment

Your Results

Turn In

Documentation / Electronic Health Record

Transcript

is ar stu ed d vi y re aC s o ou urc rs e eH w er as o. co m

Overview

Subjective Data Collection Objective Data Collection Education & Empathy Documentation Self-Reflection

Lab Pass

Document: Vitals

Document: Provider Notes

Document: Provider Notes Student Documentation Subjective

Patient Info: Esther Park, 78 years, Asian female

CC: Patient states that they are "having pain in her belly" and that she is having trouble "going to the bathroom."

Model Documentation

Ms. Park reports that she is “having pain in her belly.” She experienced mild diarrhea three days ago and has not had a bowel movement since. She reports that she has been feeling some abdominal discomfort for close to a week, but the pain has increased in the past 2-3 days. She now rates her pain at 6 out of 10, and describes it as dull and crampy. She reports her pain level at the onset at 3 out of 10. She is also experiencing bloating. She did not feel her symptoms warranted a trip to the clinic but her daughter insisted she come. She describes her symptoms primarily as generalized discomfort in the abdomen, and states that her lower abdomen is the location of the pain. She denies nausea and vomiting, blood or mucus in stool, rectal pain or bleeding, or recent fever. She denies vaginal bleeding or discharge. Reports no history of inflammatory bowel disease or GERD. Denies family history of GI disorders. Her appetite has decreased over the last few days and she is taking small amounts of water and fluids. Previously she reports regular brown soft stools every day to every other day.

HPI: The patient, Ms. Park, came into the office complaing of abdominal pain and not being able to have a bowel movement. She states that this pain started 5 days ago and has gotten worse over the past 2 to 3 days. The pain is in the lower abdomen and does not radiate. She does not have pain anywhere else. She states that her current abdominal pain could be rated a 6 out of 10. She describes the pain as "dull and crampy." She states that it does get worse sometimes, especially after physical activity or eating. She states that resting does help, but the only treatment she has pursued is "taking small sips of warm water," a method her friend infromed her of. This has not been an effective treatment. She states that she is not being able to go about her normal daily activities due to the pain. She also reports a low energy level. She is currently constipated, and issue that she has no history of. She has been constipated for about 5 days, but has not pursued any treatment. She had a bout of diarrhea about 3 days ago that she described as "loose and watery." It lasted for one day. Before the onset of the abdominal pain 5 days ago, the patient states that they had normal bowel habits, but has not had a movement in 3 days. No mucus or blood in This study source was downloaded by 100000757529999 CourseHero.com on 04-30-2021 stool. Patient from states that the frequency of her 02:12:16 GMT -05:00 https://chamberlain.shadowhealth.com/assignment_attempts/4238251 https://www.coursehero.com/file/36352067/NR-509-Abdominal-Pain-Documentation-Shadowpdf/

1/5

12/10/2018

Abdominal Pain Physical Assessment Assignment | Completed | Shadow Health

Student Documentation

Model Documentation

urination has had a small decrease, as well as a darker yellow color. There is no blood in her urine. Current Meds: Patient takes Accupril 10mg daily for hypertension. She does not take any over the counter medication. Allergies: Patient has a latex allergy. No food, medication, or environmental allergies noted. Past Medical: Patient does have hypertension. Patient has no history of gastro issues, heartburns, or ulcers. She has not had appendicitis. She did have Cholecystectomy at 42 and a caesarean section at 40. No other major medical issues or hospitilizations. Patient is up to date on vaccines except for her seasonal flu shot.

is ar stu ed d vi y re aC s o ou urc rs e eH w er as o. co m

Social History: Patient eats a failry healthy diet and no fiber supplements. She drinks around 6 glasses of water a day and has no changes in thirst level. She does not drink caffeinated beverages. Patient denies any smoking or illicet drug use. She usually has around 4 drinks per month, usually white wine. She seems her doctor regularly and states that she is in good health for her age. Last colonoscopy was 10 years ago. She is generally physically active, but not recently due to the abdominal pain. She attends fitness class, gardens, and considers herself independent. She has had three pregnancies. She has a strong support system as she lives with her daughter. She is a widow. Her husband of 50 years passed away 6 years ago. She currently dates a man named Max who she is sexually active with. No vaginal intercourse, though, just oral sex.

Family History: Mother: passed away at age 88 from strok. Had hypertension and Type II diabetes. Father: Passed away at age 82 and she had hypertension and high cholesterol. Maternal grandparents: history of coronary artery disease and Type II diabetes. Paternal grandparents: History of obesity, hypertension, and CVAs. Siblings: 80 year old brother with hypertension, high cholesterol, and prostate cancer. 81 year old brother with hypertension. Son: 48 and healthy. Daughter: 46 and healthy. ROS:

General: Patient denies any fever or chills. She notes feeling exhausted lately.

Gastro: Patient notes some bloating, increased gas, loss of appetite. She denies any nausea or vomiting. She denies any changes in weight. Genitourinary: Patient denies any pain while urinating, no incontinence, no history of UTIs, no history of gyno issues, no vaginal bleeding or abnormal discharge. Started menopause at 45. No bladder or kidney issues.

This study source was downloaded by 100000757529999 from CourseHero.com on 04-30-2021 02:12:16 GMT -05:00 https://chamberlain.shadowhealth.com/assignment_attempts/4238251 https://www.coursehero.com/file/36352067/NR-509-Abdominal-Pain-Documentation-Shadowpdf/

2/5

12/10/2018

Abdominal Pain Physical Assessment Assignment | Completed | Shadow Health

Student Documentation

Model Documentation

Respiratory: Patient denies any coughing or sore throat. Denies any difficulty breathing or chest pain.

Objective Ms. Park seemed to be in distress and pain, but she was alert and answered questions fully. She seemed to be in good hygiene and was pleasant. HEENT: Skull and facial features were symmetric. Patient's face was flushed. Nose and mouth muscus membranes were pink and moist. Normal turgor of skin with no tenting.

• General Survey: Uncomfortable and flushed appearing elderly woman seated on exam table grimacing at times. Appears stable but mildly distressed.

RESPIRATORY: Breath sounds were present and clear in all areas, with no adventituous sounds. Breathing did not seem labored and she was speaking well.

• HEENT: Mucus membranes are moist. Normal skin turgor; no tenting.

is ar stu ed d vi y re aC s o ou urc rs e eH w er as o. co m

CARDIO: No lower extremity edema. S1 and S2 heart sounds audible, with no extra sounds. No S3 or S4 rubs.

• Cardiovascular: S1, S2, no murmurs, gallops or rubs; no S3, S4 rubs. No lower extremity edema.

ABDOMINAL: Abdomen was symmetrical and flat. Some scarring is evident from past cholecystectomy (RUQ) and caesarean section (midline suprapubic area). Abdominal aorta had no bruit. Bowel sounds were normoactive in all quadrants. All arteries had no bruit. No friction rub in liver or spleen. Percussed abdomen found some dull areas and some tympanic areas. Spleen was tympanic. Liver was between 6 and 12 cm. No CVA tenderness. Palpation found tenderness in the lower left quadrant with guarding and distension. Palpable mass was found in lower left quadrant. Aortic width was 3cm or less. Liver palpable. Spleen not palpable. Bladder not palpable. Kidneys not palpable. Rectal exam: No hemorrhoids, no fissures, no ulcers, strong sphincter tone, fecal mass located in fecal vault

Pelvic exam: No inflammation or irritation of vulva, no abnotmal discharge, no bleeding, no growths or masses, no tenderness.

• Respiratory: Respirations quiet and unlabored, able to speak in full sentences. Breath sounds clear to auscultation. • Abdominal: 6 cm scar in RUQ and 10 cm scar at midline in suprapubic region. An abdominal exam reveals no discoloration; normoactive bowel sounds in all quadrants; no bruits; no friction sounds over spleen or liver; tympany presides with scattered dullness over LLQ; abdomen soft in all quadrants; an oblong mass is noted in the LLQ with mild guarding, distension; no organomegaly; no CVA tenderness; liver span 7 cm @ MCL; no hernias. • Rectal: No hemorrhoids, no fissures or ulceration; strong sphincter tone, fecal mass in rectal vault. • Pelvic: No inflammation or irritation of vulva, abnormal discharge, or bleeding; no masses, growths, or tenderness upon palpation. • Urinalysis: Urine clear, dark yellow, normal odor. No nitrites, WBCs, RBCs, or ketones detected; pH 6.5, SG 1.017.

Urinalysis: Urine was clear and dark yellow, normal odor, No abnormal findings, pH was 6.5, SG was 1.017.

Assessment

Lower left quadrant abdominal mass. 1. Constipation: the mass in the LLQ and the fecal matter in the rectal vault point toward constipation. 2. Obstruction: The tenderness that the patient felt, along with the constipation and the episode of diarrhea, could point toward an intestinal obstruction. 3. Diverticulitis: The tenderness and constipation could be signs of diverticulitis, but as the patient is not running a fever or vomiting, I believe that this is less likely.

LLQ abdominal mass. Differential diagnoses include constipation, diverticulitis, and intestinal obstruction.

3/5

12/10/2018

Abdominal Pain Physical Assessment Assignment | Completed | Shadow Health

Student Documentation

Model Documentation

Plan Diagnostics: I would like to order a CT scan or an x-ray to identify the mass in the patient's LLQ. I would also like to order a CBC as this can help diagnose diverticulitis if the white blood cell count is elevated. Medication: Depending on the test results, I might prescribe an over the counter nonstimulant laxative like Miralax to help the patient with constipation.

Referral: Depending on the test results, like a possible diagnosis of diverticulitis, she might need a referral to a gastrointeroligist for further testing.

Follow up: I educated the patient on worsening symptoms that should prompt her to seek mergency care including a fever, vomiting, or if the pain worsens significantly. If nothing changes, I would like to see her back in a week. If it is simply constipation and she is able to have normal bowel movements again and the pain has subsided, she should be okay until her next check-up.

Comments

Medication • None at this time Education • Educate to increase/maintain fluid intake • Diet is important in maintaining colon health. Pending diagnostic test results, educate Ms. Park to eat a diet rich in fiber such as whole wheat, pears, and many other fruits, vegetables and oats

is ar stu ed d vi y re aC s o ou urc rs e eH w er as o. co m

Education: I educated the patient on the importance of a fiber rich diet. This included information on foods high in fiber like fruits and vegetables, as well as a suggestion for the use of supplements like Metamucil to keep her regular. I also educated the patient on the importance of remaining hydrated and the effects that dehydration can have on the gastrointstinal system. I asked her to keep track of all the water she drank in a day so that she could remind herself to stay hydrated.

Diagnostics • Abdominal x-rays or CT scan to assess for obstruction • CBC to assess for elevated WBCs associated with diverticulitis and electrolyte profile to evaluate electrolyte and fluid status

Referral/Consultation • Pending diagnostic test results, may need GI or surgical referral Follow-up Planning • Instruct the patient that is she develops a fever, nausea, vomiting, and worsening abdominal pain, she should seek immediate medical attention • Revisit clinic in 5-7 days for follow up and evaluation

Olivia Mgbeokwere (01 Dec 2018, 09:45 AM CST):

Dear Student, Congratulations! You did a good job with this case study. Of course, there is always room for improvement. Please take time to review your results and the feedback provided by Shadow Health. Compare your performance with the model note. It is important to understand where you may have missed opportunities to be more effective or enhance your skills. Be sure to use" OLDCART"

How confident are you in your diagnosis? How did you determine the severity of Esther's complaints? What findings from the history and physical exam helped you to make your diagnosis? Have you ruled out bowel obstruction completely? What about ordering an abdominal series x-ray or CT scan? Be prepared to discuss your responses to these questions during the Debriefing Session for Week 5. Let me know if you have any questions or concerns. Dr. O

4/5

12/10/2018

Abdominal Pain Physical Assessment Assignment | Completed | Shadow Health

is ar stu ed d vi y re aC s o ou urc rs e eH w er as o. co m

5/5

6/6/2020

Focused Exam: Abdominal Pain | Completed | Shadow Health

Focused Exam: Abdominal Pain Results | Turned In Physical Assessment - June 2020, NUR 3010 Return to Assignment (/assignments/351028/)

Your Results

Reopen (/assignment_attempts/7049123/reopen Lab Pass (/assignment_attempts/7049123/lab_pass.p

Education & Empathy : 4 of 4 (100.0%)

Overview

Subjective Data Collection Objective Data Collection Education & Empathy Documentation Care Plan

is ar stu ed d vi y re aC s o ou urc rs e eH w er as o. co m

Transcript During the patient interview, there are a number of opportunities to provide patient education and empathy. The opportunities listed below are those identified by nursing experts to be of particular importance to this patient. A Model Statement is provided as an example of an appropri response to each opportunity. Opportunities marked as Not Encountered are opportunities that were not elicited in the interview Opportunities marked as Not Followed Up are missed opportunities that were present in the interview, but where no statements were ma Opportunities marked as Followed Up were followed up by students, and include the dialogue between student and patient

1 Pain and Constipation

Followed Up

2 Fatigue and Activity Level

Followed Up

Description: Ms. Park describes being more fatigued and having less energy for her daily activities.

What is your activity level?

Questio 10:57 PM ED

Normally, I garden, take walks, I even do exercise classes at the center. But since getting sick. . .it's not that I have difficulty taking care of myself; I just don't have as much energy to do so.

Empathiz 10:57 PM ED

I appreciate that.

Do you exercise?

Questio 10:58 PM ED

I am sorry to hear that.

Yes, I usually love exercise--water aerobics, Pilates. . . I take classes at the community center. But with this pain and feeling so uncomfortable this week, I've skipped my classes. I don't like that . . . I feel out of sorts.

It sounds like you stay active and healthy which is great!.

Empathiz 10:58 PM ED

Thank you much.

This study source was downloaded by 100000757529999 from CourseHero.com on 04-30-2021 02:04:40 GMT -05:00 https://app.shadowhealth.com/assignment_attempts/7049123 https://www.coursehero.com/file/63203961/Esther-Parks-Focused-Exam-Abdominal-Pain-Education-and-Empathypdf/

1/3

6/6/2020

Focused Exam: Abdominal Pain | Completed | Shadow Health Do you exercise?

Questio 10:59 PM ED

Im sorry that this makes you uncomfortable.

Empathiz 10:59 PM ED

Well, thank you.

Model Statement: "I’m sorry you’ve been more tired and haven’t been able to live your daily life with your normal vigor. It’s always unpleasant when an illness makes you feel unlike yourself. Rest assured that we will work to improve your energy levels and get you able to participate in your regular activities."

3 Diet and Fiber

Followed Up

is ar stu ed d vi y re aC s o ou urc rs e eH w er as o. co m

Description: Ms. Park describes her dietary habits and reveals a lack of consistent fiber intake.

Do you take fiber supplement?

Questio 10:55 PM ED

No, I don't take any extra fiber. I hadn't quite considered it . . .

Keeping an eye on fiber intake is a great way to start. The USDA recommends that adults eat about 28 grams of fiber per day.

Educa 10:56 PM ED

Alright, that's helpful to know.

Model Statement: "Thanks for telling me about your diet. The USDA recommends that adults eat around 28 grams of fiber per day, which is several servings of fruits, vegetables, and whole grains. Enough fiber can help regulate your digestive system and prevent gastrointestinal upsets, so let’s talk about ways you might increase your fiber intake."

4 Fluid Intake

Followed Up

Description: Ms. Park describes drinking 1-2 glasses of water a day.

Do you drink water a lot?

Questio 11:11 PM ED

A glass or two a day, I would say. Since getting sick, even less--I haven't been as thirsty.

It is important to drink water to help with bowel movement.

Educa 11:11 PM ED

Well, now I know.

Model Statement: "It’s a really healthy practice to be drinking water every day, and it’s great that you are! You have room to drink even a few more glasses per day, or as much as is comfortable. This would help prevent dehydration and increase your overall health, especially in your gastrointestinal system."

Comments This study source was downloaded by 100000757529999 from CourseHero.com on 04-30-2021 02:04:40 GMT -05:00 https://app.shadowhealth.com/assignment_attempts/7049123 https://www.coursehero.com/file/63203961/Esther-Parks-Focused-Exam-Abdominal-Pain-Education-and-Empathypdf/

2/3

6/6/2020

Focused Exam: Abdominal Pain | Completed | Shadow Health

If your instructor provides individual feedback on this assignment, it will appear here.

is ar stu ed d vi y re aC s o ou urc rs e eH w er as o. co m

(800) 860-3241 | Help Desk (https://support.shadowhealth.com/) | Terms of Service (/static/terms_of_service) | Privacy Policy (/static/privacy_policy) | Patents (https://www.shadowhealth.com/patents)

3/3