Abdominal Assessment Case Study

Abdominal assessment can be described as the evaluation of the abdomen by a doctor or health care provider. Mainly it is important because it can generate vital information about the patient’s internal organs. The assessment also prevents further complications by detecting the patients’ health problems earlier. This examination focuses on the assessment findings for Tina and Esther. It is important to note that abdominal assessment includes four-step procedures, and for a successful assessment, the procedure must be followed in this order. First, you begin with inspection, then auscultate, then percus, and finally, palpate. To better understand this, we look at the steps each at a time. Accurate results from the assessment are achieved if we do not change the order of the steps, as it may tamper with the frequency of bowel sounds.

Assessment findings for Tina include that on inspection, the abdomen was observed to be symmetric soft, and non-tender with no distensions. With a stethoscope on the diagram, normal gurgling sounds are heard (Lindsey, M. (1989). There was minimal gut activity. On percussion, there was some resonance sound. On palpitation, the nurse checked the sensation and sound experienced under the skin of the abdominal walls while looking for any sort of abdominal masses present. In this case, no pain or tenderness was observed, hence no signs of infection.

The assessment findings for Ester included that the abdomen was more rigid and tender with some distensions; the patient had ascites that may also have been observed as hepatomegaly on auscultation. The patient had pain in the lower abdomen and pain while going to the bathroom that was suggestive of some gastrointestinal pathology. There were also some abdominal masses and tenderness on the left side (Jarvis, 2018).

SMART goals based on the assessment of Tina are to learn how effective my physical examination techniques are and how accurate the technique is to ensure that the patient does not have or experience any abdominal abnormalities or infections. SMART goals for Ester first include an urgent report to the primary care provider and help to identify the underlying problem that may have caused the problem. I would also ensure that all my recorded findings are correct and pathologically valuable for determining the etiology of the disease.

Health promotion opportunities include activities that help maintain and avoid pathologies that harm the patient. This includes evidence for dietary quality, exercise, and healthy eating styles especially watching the dietary calories and other sedentary behavior that may cause a change in the health she is in right now. Health promotion opportunities for Ester aim at reducing weight and obesity management. The patient is found with obesity with abdominal ascites and tenderness on palpitation that may indicate an infection. An immediate intervention includes a single bout of physical activity that is moderate intensity and may have beneficial health outcomes. This enhances sleep, helps to lessen anxiety, and controls blood pressure. In the long term, regular physical exercise for health benefits helps prevent chronic illnesses such as heart disease and cancer. This encourages a healthy weight and bone strength. They should also avoid smoking and cut on alcohol consumption, which may be risk factors for the development of other complications. Moreover, I would educate the patient on dehydration, encouraging them to take a lot of fluids to ensure proper hydration.

In conclusion, the first step you start with is inspection which includes viewing the abdomen in four quadrants; inspection involves a healthcare provider standing on the patient’s right side, with your patient lying face upwards. Inspection can be done for various reasons, including symmetry or shape, where you observe if it’s flat, rounded, convex, or concave. The second step is auscultating. In auscultating, sounds are heard internally from the human body. The third procedure to follow is percussion. As the word suggests, it is an assessment that involves drumming the body to generate sounds of the underlying surface of the skin. In all four quadrants of the abdomen, percuss using appropriate methods like striking the abdomen with your middle finger, and the last step is palpation to observe for any masses. The SMART goals and the health promotion activities were discussed after the physical exam.

References

O’Laughlen, Mary C. RN, FNP-BC, Ph.D. Making sense of abdominal assessment. Nursing Made Incredibly Easy! 7(5):p 15-19, September 2009. | DOI: 10.1097/01.NME.0000359666.97784.7b

Lindsey, M. (1989). Abdominal assessment. Orthopaedic Nursing, 8(4), 34-38.

Jarvis, C. (2018). Physical Examination and Health Assessment-Canadian E-Book. Elsevie