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Learning the required components of documenting a problem based subjective and objective assessment of gastrointestinal system. Identify abnormal findings.

Learning the required components of documenting a problem based subjective and objective assessment of gastrointestinal system. Identify abnormal findings.

Documentation of problem based assessment of the gastrointestinal system.

Purpose of Assignment:

Learning the required components of documenting a problem based subjective and objective assessment of gastrointestinal system. Identify abnormal findings.

Course Competency:

Prioritize appropriate assessment techniques for the gastrointestinal, breasts, and genitourinary systems.

Instructions:

Content: Use of three sections:

· Subjective

· Objective

· Actual or potential risk factors for the client based on the assessment findings with description or reason for selection of them.

Format:

· Standard American English (correct grammar, punctuation, etc.)

· Clients Presentation: ( Your client can make up whatever they want. They can be as dramatic. Have fun with it!)

· Subjective Data (4 points): (Review History questions in power point and on page 534-535 of text.)

· Objective Data (4 points):

· Inspection: What is the shape and size of the abdomen? Any masses or pulsations upon inspection? Skin smooth? Striae, scars, lesions?

· Auscultation: Bowel Sounds Present in all 4 quadrants? Hypoactive, Normoactive, etc. Any bruits upon auscultation?

· Percussion: Tympany in all 4 quadrants?

· Palpation: Abdomen soft, firm? Any enlarged organs? Masses? Tenderness?

· Any other objective data you found important to document?

· Describe 2 Actual/Potential Risk Factors ( 2 points):

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