physical assessment

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Gastrointestinal assessment

Hawa wolopa

Rasmussen College

COURSE#: NUR2180 Physical Assessment

Professor Casey Kelly

0ct 21, 2020

Title of Paper

Subjective Information

The patient is a 41-year-old Caucasian who is admitted with the diagnosis of gastrointestinal bleed. The patient is currently on Omeprazole, theanine, vitamin B, and folate supplement. The patient is allergic to morphine, Ibuprofen, and tetracycline. The patient states that 5 minutes before the nurse entering his room, he vomited bright red blood into the trash can. He also says that I should not have eaten the food because not eating has been the only thing not making me sick since being here. The patient also reported that he is feeling nauseous, exhausted, and anxious. When asked about his appetite, he states that he desires, but feels sick to his stomach and has been throwing up whenever he eats. He says that he feels more tired after throwing up. The patient denies having ulcer and gallbladder diseases. Patients report no symptoms of appendicitis or colitis but complain burning sensation in the Left upper quadrant that does not radiate and indigestion; report pain 4/10 on the scale of one to ten. She states that he feels much better when he takes Antacids—the patient report not having BM every day without discomfort.

Objective Information

On inspection of the patient, vital signs obtain Temp 36.5, HR 124Bpm, RR 24, and ` BP100/62mm Hg. Spo2 93%, weight 55kg, (last weight was 65kg) patient height is 178. Upon inspection: the patient abdomen distended asymmetrically. Umbilicus everted with significant ascites. Skin jaundiced with prominent vein distention. No open area, redness, or bruises noted. Auscultation: Bowel sounds noted hyperactive in all four’s quadrants, no swashing sound noted in all quadrant—palpation: Abdomen firm and slightly tender with muscle guarding. Skin feels warm touch, and intact.

Risk Factors

The patient might be at risk for Gastritis due to the bright red blood noted in his Emesis, feeling nauseated, ingestion. Also, Gastritis is inflammation of the stomach lining, and it depends on the location of the inflammation. Gastritis also leads to ulcers if not on time. The patient is also at risk for deficient fluid volume, leading to decreased urine output, poor or dry skin, increased thirst, and reduced blood pressure. Fluid loss leads to loss of electrolytes with the GI tracts.

References

Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2019). Nursing Care Plans : Guidelines for Individualizing Client Care Across the Life Span: Vol. 10th edition. F.A. Davis.