Assesment 1: Assessing the Abdomen A woman went to the emergency room for severe abdominal cramping. She was diagnosed with diverticulitis; however, as a precaution, the doctor ordered a CAT scan. The CAT scan revealed a growth on the pancreas, which turned out to be pancreatic cancer—the real cause of the cramping.

Assesment 1: Assessing the Abdomen A woman went to the emergency room for severe abdominal cramping. She was diagnosed with diverticulitis; however, as a precaution, the doctor ordered a CAT scan. The CAT scan revealed a growth on the pancreas, which turned out to be pancreatic cancer—the real cause of the cramping.

Case Study: Assessing the Abdomen

Gastrointestinal disorders are common encounters in nursing practice with considerable public health impacts. Nurses and other healthcare providers should perform comprehensive history taking and physical examinations to develop accurate diagnoses and care plans. Therefore, this essay examines J.R.’s case study. J.R. presented to the hospital with complaints of having generalized abdominal pain that began three days ago. He has been experiencing diarrhea that has been unresponsive to any treatments adopted by the patient.  The essay analyzes additional subjective and objective information that should be obtained from the client if subjective and objective data supports the assessment, diagnostic tests, and possible differential diagnoses.

Additional Subjective Information

Additional subjective information should be obtained to guide the development of an accurate diagnosis. First, information about the things that might have led to the abdominal pain should be obtained. This includes data such as diet, alcohol consumption, or possible trauma that could have led to the symptoms. Information about previous experiences of stomach pain should also be obtained. A previous history of stomach pain will help the nurse determine if the condition is acute or chronic. In addition, the nurse should determine if JR experienced a similar pain when he experienced gastrointestinal bleeding four years ago. Information on previous treatments for the GI bleed should be obtained to guide the current management. The nurse should also seek information about the characteristics of stomach pain (Maret-Ouda et al., 2020). For example, information on whether the pain radiates elsewhere should have been obtained to rule out causes such as pancreatitis.

Information about the character of the diarrhea should also be obtained. Information such as blood-stained diarrhea would help the nurse to develop a potential diagnosis of gastrointestinal tract bleeding. Associated symptoms such as vomiting should also be obtained. This is important because symptoms such as projectile vomiting will indicate potential problems such as pyloric stenosis. Information about changes in the client’s weight over the past few months should also be obtained. Unintentional weight loss could indicate other health problems such as cancer of the gastrointestinal system. Information on changes in appetite should also be sought. Early satiety could indicate problems such as hypertrophic pyloric stenosis. The nurse should also obtain information about the factors that relieve, precipitate, or worsen the stomach pain. For example, a diagnosis of peptic ulcer disease will be made if the symptoms worsen 15-30 minutes after eating (Sverdén et al., 2019). A diagnosis of gastroesophageal reflux disease will be made if the symptoms worsen when JR lies down and improves with sitting upright.

Additional Objective Information

The nurse should obtain additional objective information from JR to make an informed diagnosis and develop a patient-centered care plan. Firstly, information about JR’s general appearance should be documented. This includes information such as his grooming, weight, alertness, and orientation. A comprehensive review of all the body systems should have also been done. For example, the assessment of the respiratory system is inadequate. Information such as the presence or absence of nasal flaring, wheezes, crackles, rhonchi, and peripheral or central cyanosis should have been documented (Katz et al., 2022). The assessment of the cardiovascular system should have extended to information such as the presence or absence of jugular venous distention or peripheral edema.

The information in the assessment of the gastrointestinal system is inadequate. Additional information such as the presence or absence of abdominal scars, organomegaly, pulsations, ascites, and visible blood vessels should have been documented. This is important because information such as palpable abdominal pulsations would indicate aortic abdominal aneurysm. Information about any abdominal pain on palpation and the location of the pain should have also been obtained and pain rating on a pain rating scale.  The nurse should have also assessed the skin for capillary refill, turgor, cyanosis, and edema (Haque & Bhargava, 2022). Low capillary refill and poor skin turgor could indicate problems with circulation and hydration.

If Subjective and Objective Data Supports the Assessment

Subjective assessment data is the information a patient gives about their health problems. Subjective data supports JR’s assessment. Some of the subjective data include his chief complaints, history of the chief complaints, past medical