Question

A 55-year-old male client is admitted to the nursing unit with complaints of abdominal pain that is sharp and burning. The client gives a history of experiencing bloating and gas after eating and heartburn during the night. The client had a colonoscopy done 5 years ago that revealed six polyps, which were removed, biopsied, and found to be negative for cancerous cells. Upon interviewing the client, the nurse notes that the abdominal pain increases when the client eats fried and spicy foods, drinks alcoholic beverages, or engages in strenuous activity. The client works as a package delivery carrier for a major parcel company. Picking up packages that weigh 25 to 50 lb (11 to 23 kg) is an expectation of his job. Lately, this has become difficult. The client’s family history is positive for cancer. The client’s mother died from stomach cancer, and the father had prostate cancer that benefited from proton therapy treatments. During the examination of the abdomen, the nurse finds that the client’s abdomen is guarded and distended.

Questions:

1. Associated signs and symptoms may provide diagnostic evidence to support or rule out a particular origin of pain. What other factors should the nurse consider when assessing this client?

2. The nurse is teaching a nursing student how to perform an abdominal assessment. Explain the order for the abdominal assessment.

3. To develop a client-specific plan of care, what additional information is important for the nurse to know about this patient?

4. What abnormal/concerning findings do you note in the case study above?

5. What nursing diagnostic statement(s) will guide your plan of care?
6. What interventions will you initiate based on this priority?
7. How will you assess the efficacy of these interventions?

Answer 1

Ans) 1) Components of pain assessment include:

a) history and physical assessment;

b) functional assessment;

c) psychosocial assessment;

d) multidimensional assessment.

Patient's behaviors and gestures that indicate pain (e.g. crying, guarding, etc.), Some try to hide the pain, internal factors are some factors that nurse needs to understand.

2) With abdominal assessment, you inspect first, then auscultate, percuss, and palpate. This order is different from the rest of the body systems, for which you inspect, then percuss, palpate, and auscultate.

3) Knowing the patient” is an essential element to the practice of nursing. Every nurse should have the ability to obtain the clinical and personal information needed to know the patient. Additionally, the information should be consistent across all nurses and only vary based on the individual patient's care needs.

4)Case Study?
Section 1 – Patient Status. This section includes demographic information, the patient's medical history, and the current patient's diagnosis, condition, and treatment.
Section 2 – Nursing Assessment.
Section 3 – The Current Treatment and Recommendations for Improving It.

- Case studies are often used in exploratory research. They can help us generate new ideas (that might be tested by other methods). They are an important way of illustrating theories and can help show how different aspects of a person's life are related to each other.