Advance Health Essay: Abdomen and Gastrointestinal System Assessment

Advance Health Assessment: Abdomen and Gastrointestinal System Assessment
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Introduction
Some diseases may affect gastrointestinal (GI) and abdomen. Therefore, it would be prudent for the medical practitioner or a nurse to conduct an advanced medical assessment of the patient. It is worth noting that GI and abdomen organs are close to one another it would be difficult to conduct an assessment on the organ (Ball et al., 2017). Ball et al., (2015) postulate that numerous exclusive assessment findings are connected to distinct gastrointestinal disorders or conditions. The assessment of the patient’s condition would enable the nurse to control or manage disorders that are associated with gastrointestinal emergencies admitted.
Assessment of Abdomen
When conducting an assessment in the abdomen of the patient, the nurse would be expected to collect both subjective and objective data. The components of the data to be collected include the chief complaint, current health condition or status, present lifestyle, psychosocial status, family history, and physical assessment (Dains, Baumann &Scheibel, 2015).
Source:Lampert, (2016)
Subjective Assessment
Patient Information
Chief Complaint
The patient complained about of stomach that was hurting.
Patient Information
Initials: Mrs. JR Age: 47 years old Sex: Female Race: Caucasian
Patient’s Medical and Social History
Mrs. JR went to the hospital complaining of a hurting stomach, and she also had been diarrhea. She also complained of a general pain in the abdomen that began three days ago. She also reported that she had not taken any kind of medication because she was not sure of the nature of disorder she had. She opined that the pain is currently at 5/10, and when it started it was as much as 9/10. However, she has been able to eat although with some nausea after eating.
Past Medications:
The current medications she is using include Lisinopril 10mg, Metformin 1,000mg, Amlodipine 5mg, and Lantus 10 units.
Allergies
There is no known drug, food, or smell allergy.
Past Medical History
Mrs. JR informed the nurse that she was also diagnosed with Hypertension, Diabetes, and bleeding in the Gastrointestinal System four years ago.
Social History
The patient also pointed out that she has never smoked in her life, though she admitted that she occasionally takes alcohol. Finally, she reported that she is married with three kids; one girl and two boys.
Important Family History
Other than her personal medical and social history, the patient also provided the history of medical condition of her family lineage. Familial Hypercholesterolemia is quite important because it may lead the nurse or medical practitioner to figure out the possible cause of the abdominal pain (Dains, Baumann &Scheibel, 2015). The patient reported that there was no history of colon cancer in their family lineage. However, she reported that her father had diabetes mellitus type 2 (DMT2); while her mother had high blood pressure, hyperlipidemia, and gastroesophageal reflux disease (GERD).
Objective Data Collection
General: Mrs. JR is a fairly developed white woman, who seems to be alert, and is w...