nursing

Analysis of SOAP Case Note Study: Abdominal Assessment
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Analysis of SOAP Case Note Study: Abdominal Assessment
The patient's chief complaint was about the stomach pain and diarrhea. There are two problems that need to be evaluated in the subjective portion of the documentation: abdominal pain and diarrhea. The first problem to be evaluated is the abdominal pain. The subjective documentation of the patient confirms of having generalized abdominal pain. However, this information do not specify on which part of the abdomen does the pain is hurting in particular. Although the patient indicated the intensity of pain that he experiences, additional subjective information should be ask from the patient such as the quality of pain, the location of the pain, and any form of pain control measures that the patient had used other than medicinal control to cope up with pain since there are instances that the pain is perceived as less severe and sometimes pain is perceived as severe. Also, the effects of the pain on the daily activities of the patient should be ask, such as if the pain deprives sleep or if the pain affected the patient’s appetite, decrease or the same, due to abdominal pain (Ball, Dains, Flynn, Solomon, & Stewart, 2018). The patient’s subjective information indicates that he could eat with nausea after eating, but did not indicate if it was decreased or the same. These additional subjective data will indicate the presence of any pertinent positives and negatives to be documented that would support the differential diagnosis of the possibility of other diseases (Sullivan, 2012). For example, if the patient has a recurring pain on the right lower quadrat of the abdomen, this could be an indication of appendicitis, but if the patient's daily activities were not changed like a decrease in appetite, a differential diagnosis might indicate another diagnosis since appendicitis usually presents the patient with loss of appetite. The chief complaint is “stomach hurts,” this could be translated as a generalized abdominal pain, but the location specified will rule out other diagnoses because of their absence in the specified area (Sullivan, 2012). The next problem to be evaluated is the diarrhea. The patient is a white male, which indicates that the most common illness in families in the United States related to diarrhea is acute gastroenteritis (Dains, Baumann, & Scheibel, 2016). The subjective data did not present elaborated descriptions about the information regarding diarrhea, questions such as the frequency of the occurrence of stools? What is the estimated volume of the stools? At what intervals does diarrhea occur? And, how the appearance of the stool looks like, such as color, appearance of blood, and if stools are formed or purely liquid? This information is important, since it will indicate possible the symptoms of the colon (Dains, Baumann, & Scheibel, 2016). Also, since the pain differs in intensity, does the pain relived by the passage of gas? The only information present is the onset of diarrhea which is three days ago.
In the objective part of the documentation, additional laboratory and diagnosis studies could be done, but since the pain...