Assessment of the Abdomen assignment

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.

Subjective Data

  • 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

Objective Data

  • 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

  1. What other assessments should be included for this patient?
  2. What questions should the nurse ask with regard to the abdominal pain?
  3. From the readings, subjective data, and objective data, what is the most probable cause of the abdominal pain?
  4. What should be included in the plan of care?
  5. 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)

 

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