NURS 4520- Esther Park Shadow Health Abdominal Assessment

Ms. t:.stner ParK 1s a / -year-old woman who comes to the clinic complaining of abdominal pain. She reports that the pain isn’t severe, but that her daughter was concerned and brought her in. It is very important to determine whether or not the situation is an emergency and that the underlying cause of Esther’s discomfort. Be su to inquire about a variety of psychosocial factors related to the GI system, including h diet, toilet habits, immunizations, recent travel, etc. This case study will offer you the opportunity to take a complete surgical, reproductive, and current sexual history. Durir her physical examination, take particular note as to where Mrs. Park verbalizes pain during palpation so that you may synthesize verbal and non-verbal cues. Be sure to apply the supportive information learned in this week’s concept lab to your critical thinking process in this case study.

What is the care plan for esther park shadow health abdominal assessment? Scattered dullness in LLQ during percussion is suggestive of feces in the colon; otherwise, her abdomen is tympanic. Her abdomen is soft to palpation; mild guarding and oblong mass suggesting feces were discovered in LLQ. No CVA tenderness; liver span 7 cm @ MCL; no splenic dullness. Digital rectal exam revealed a fecal mass in the rectal vault. No abnormalities were noted during the pelvic exam, so pelvic inflammatory disease is not suspected. Ms. Park’s urinalysis was normal, which rules out a urinary tract infection. No signs of dehydration.

Explanation:

From the physical exam alone, I can already conclude the patient will need a manual disimpaction. The physical examination also suggests that constipation is an issue. The LLQ dullness is suggestive of feces. As we know, the LLQ is where the descending and sigmoid colon are located. The sigmoid colon obviously leads to the rectum which is where a fecal mass is identified. We know there is no hepatomegaly, the spleen is WNL, UA is negative, etc. It seems as though the primary cause for the abdominal pain is the fecal impaction. I would also say this is emergent, because there is mild guarding on physical examination. Even though it is just mild, it still suggests inflammation and inflammation suggests infection. The patient should be sent to the ER, for routine labs (CBC, CMP, Lactic, etc) and imaging. NURS 4520- Esther Park Shadow Health Abdominal Assessment

Objective Data Collection: 21 of 21 (100%)

S ubjective Data Collection

O bjective Data Collection

Correct

Partially correct

Incorrect Missed

E ducation & Empathy D ocumentation

Inspected head and face 1 of 1 point

C are Plan

Skull Symmetry (1/3 point)

Symmetric Asymmetric

Facial Feature Symmetry (1/3 point)

Symmetric Asymmetric

Appearance (1/3 point)

No visible abnormal findings Flushed appearance

Rash or lesion

Skin growths (freckles, moles, or birth mark) Excessive hair growth

Evidence of skin trauma (scar, laceration, or bruising)

Inspected nasal mucosa 1 of 1 point

Inspected mouth 1 of 1 point

Oral Mucosa (1/1 point)

Moist and pink Dry appearance Redness

Inspected abdomen 1 of 1 point

Symmetry (1/3 point)

Symmetric Asymmetric

Contour (1/3 point)

Flat

Rounded

Protuberant Hollowed

Appearance (1/3 point)

No visible abnormal findings Rash

Striae

Bulgingaroundumbilicus

Distension

Visible masses (warts, cysts, or tumors) Freckles, birthmark, or discoloration

Excessive hair growth Scarring

Laceration, lesion, or wound Bruising

Redness Jaundice

Prominent veins

Inspected for edema in lower extremities 1 of 1 point

Right: Edema (1/4 point) NURS 4520- Esther Park Shadow Health Abdominal Assessment

No edema Pitting

Non-pitting

Right: Severity Of Edema (1/4 point)

No edema

1+ Slight pitting

2+ Deeper pit, disappears in 10 to 15 seconds

3+ Noticeably deep pit that lasts more than a minute 4+ Very deep pit that lasts 2 to 5 minutes

Left: Edema (1/4 point)

No edema Pitting

Non-pitting

Left: Severity Of Edema (1/4 point)

No edema

1+ Slight pitting

2+ Deeper pit, disappears in 10 to 15 seconds

3+ Noticeably deep pit that lasts more than a minute 4+ Very deep pit that lasts 2 to 5 minutes

Auscultated heart sounds 1 of 1 point

Heart Sounds (1/2 point)

S1 and S2 audible

S1, S2, and S3 audible S1, S2, and S4 audible

S1, S2, S3, and S4 audible

Extra Heart Sounds (1/2 point)

No extra sounds Gallops

Murmur Friction rub Valve clicks

Auscultated breath sounds 1 of 1 point

Breath Sounds (1/3 point)

Present in all areas

Diminished in some areas Absent in some areas

Adventitious Sounds (1/3 point)

No adventitious sounds Wheezing

Fine crackles Stridor

Rhonchi Rales

Location (1/3 point)

All areas clear

Adventitious sounds in anterior right upper lobe Adventitious sounds in anterior right middle lobe Adventitious sounds in anterior right lower lobe Adventitious sounds in anterior left upper lobe

Adventitious sounds in anterior left lower lobe

Adventitious sounds in posterior right upper lobe Adventitious sounds in posterior right lower lobe Adventitious sounds in posterior left upper lobe Adventitious sounds in posterior left lower lobe

Auscultated abdominal aorta 1 of 1 point

Sound (1/1 point)

No bruit Bruit

Auscultated bowel sounds 1 of 1 point

Bowel Sounds (1/2 point) NURS 4520- Esther Park Shadow Health Abdominal Assessment

Absent

Hypoactive Normoactive Hyperactive

Location Of Non Normoactive Bowel Sounds (1/2 point)

All quadrants normoactive Right upper quadrant

Right lower quadrant Left upper quadrant Left lower quadrant

Auscultated abdominal arteries 1 of 1 point

Right: Renal (1/6 point)

No bruit Bruit

Right: Iliac (1/6 point)

No bruit Bruit

Right: Femoral (1/6 point)

No bruit Bruit

Left: Renal (1/6 point)

No bruit Bruit

Left: Iliac (1/6 point)

No bruit Bruit

Left: Femoral (1/6 point)

No bruit Bruit

Percussed abdomen 1 of 1 point

Observations (1/1 point)

All areas generally tympanic

Some areas dull, some tympanic Some areas resonant

Percussed CVA tenderness 1 of 1 point

Patient Reaction (1/1 point)

Did not react Pain reaction

Percussed spleen 1 of 1 point

Spleen (1/1 point) NURS 4520- Esther Park Shadow Health Abdominal Assessment

Tympany Dullness

Percussed liver 1 of 1 point

Liver Span (1/1 point)

Smaller than 6 cm

Between 6 and 12 cm Greater than 12 cm

Palpated abdomen – light 1 of 1 point

Tenderness (1/3 point) Location Of Tenderness (1/3 point)

No quadrants tender

Tenderness reported Observations (1/3 point) No additional observations Masses Guarding Distension	Right upper quadrant Right lower quadrant Left upper quadrant Left lower quadrant
Palpated abdomen – deep		1 of 1 point
Presence Of Unexpected Mass (1/2 point) No palpable mass Palpable mass	Location Of Mass (1/2 point) No palpable mass Right upper quadrant Right lower quadrant Left upper quadrant Left lower quadrant Around umbilicus
Palpated liver		1 of 1 point
Detection (1/1 point) Not palpable Palpable
Palpated spleen		1 of 1 point
Detection (1/1 point) Not palpable Palpable
Palpated bladder		1 of 1 point
Detection (1/1 point) Not palpable Palpable
Palpated kidneys		1 of 1 point
Right (1/2 point) Palpable Not palpable	Left (1/2 point) Palpable Not palpable
Tested skin turgor		1 of 1 point
Observations (1/1 point) No tenting Tenting

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NURS 4520- Esther Park Shadow Health Abdominal Assessment