Assessment of the Abdomen (graded)
Kevin Valeri is a 64-year-old man who presents to the gastroenterologist’s office with constipation and abdominal bloating.
- Pain level is a 4/10 location = right lower abdomen
- Retired Engineer
- States he has been going to the bathroom with the help of laxatives, but not having regular movements
- Appetite is decreased, some nausea
- PMH: depression, anxiety, chronic constipation
Assessment of the Abdomen
- Vital signs: T 37 degrees Centigrade, P 64, R 16, BP 124/58
- Bowel sounds hypoactive in all four quadrants
- Medications: Lamictal 200mg daily, Lexapro 10 mg daily
- Weight = 210 lbs, last visit weight = 195
- What other assessments should be included for this patient?
- What questions should the nurse ask with regard to the abdominal pain?
- From the readings, subjective data, and objective data, what is the most probable cause of the abdominal pain?
- What should be included in the plan of care?
- What interventions should be included in the plan of care for this patient?
This can be of help:
Jarvis, C. (2016). Physical examination & health assessment (7th ed.). Philadelphia, PA: Saunders.
- Chapter 21: Abdomen
- pp. 537–566 (Structure, Function, Subjective and Objective Data, Documentation and Critical Thinking)