Abdominal Discomfort: Focused Assessment, Esther Park
Introduction
Abdominal pain is a common complaint in healthcare settings. Since the diagnosis of abdominal pain is challenging, accurate diagnosis requires advanced assessment skillsets. Abdominal assessment is an essential component of physical examination as it assists in identifying abdominal pain, masses, distention, and enlarged organs. Abdominal discomfort Essay.The nurse practitioner should develop a trustful therapeutic relationship with the patient to facilitate the collection of comprehensive data throughout the examination. The paper will thus discuss the focus of the assessment, analyze the collected objective data and subjective data, and develop a list of the relevant differential diagnoses. The paper will conclude by discussing a care plan for the patient.Abdominal discomfort Essay.
Focus of the Assessment
The focus of this paper is to discuss the assessment of an elderly female patient (Mrs. Esther Park), who presents with a chief complaint about abdominal pain. The abdominal examination should thus also encompass a careful visual examination of the abdomen, including other essential body parts. The subjective data was collected by interviewing the patient while the objective data was collected by performing a physical assessment that included abdominal examination using a pre-determined sequence through auscultation, palpation, and percussion of the abdomen.Abdominal discomfort Essay.
Subjective Component
The patient presented with complaints about abdominal pain and having difficulties going to the bathroom. She reported that the pain started five days ago when she started having difficulties going to the bathroom. The patient reported that she is not able to make bowel movements and she has not been able to go to the bathroom for almost a week. She further reported that the stomach pain and the location never change, but the pain fluctuates in intensity. Abdominal discomfort Essay.She stated that the discomfort and the pain are located in the down-low in her stomach and the pain is more towards the from, down low. She reported that the pain fluctuates and rates the pain as 2 during the physical assessment. She describes the abdominal pain as a dull cramping feeling. The patient states that she has been using warm water and rest to relieve the pain, but has not taken any medication for the pain. She reports that eating and physical activity aggravate the pain. The pain has thus affected her ability to perform activities of daily living. She denies vomiting, diarrhea, mucus, and blood in the stool, but reports that she has been having constipation for the last five days. Abdominal discomfort Essay.The patient further reports that she is less thirsty, the frequency of urination has reduced, and the urine has been darker than usual. However, she denied blood in the urine. She states that her gall bladder was removed, she has hypertension, and takes high blood pressure medication at 8.00 am every day. She denies taking over the counter medications, smoking tobacco, drinking coffee, and taking drugs. She takes alcohol once per week. She is physically active. She reports fatigue but denies breath shortness, weight changes, chills, night sweats, edema, history of stomach cancer, appendicitis, sleep problems, palpitations, chest pain, sore throat, problem swallowing, sore throat, nausea, or vaginal problem. She reports bloating, a slight increase in gas, and loss of appetite. Esther’s typical diet includes toast and fruit for breakfast; soup for lunch; and rice with fish or chicken for supper. She reports that she does not take fiber supplements or any extra fiber.Abdominal discomfort Essay.
She is allergic to latex and has a history of hypertension. Surgical history includes a CS at 40 and cholecystectomy at age 42 years. She reports that the mother had a history of diabetes. She reports that she has had two colonoscopies, and the last one was 10 years ago. She has a partner and lives with her daughter. She reports annual check-ups, a pap smear more than ten years ago.Abdominal discomfort Essay.
Objective Component
Vital signs: Hear rate 92: RR 16: blood pressure 110/70: Oxygen saturation 99%: Temp 37 C.
The patient appears uncomfortable during the interview, grimaces at times, slightly flushed cheeks, but she seems to be in stable condition.
Inspection reveals that the face is symmetric, and the mucus membranes are pink and moist. She has a scar on the abdomen under the right breast and an injury within the lower abdomen midline (suprapubic region). Abdominal discomfort Essay. Order this paper