Verified Document

Assessment Of A Patient's Abdominal Pain Essay

Related Topics:

Assessing the AbdomenAbdominal pain has proven to be a major issue facing emergency room doctors since the diagnosis process is relatively complex. Meisel (2011) contends that doctors in emergency rooms do not fancy diagnosing and treating abdominal pain because it entails dealing with bodily fluids, complex internal examinations, and a wide range of diagnostic tests and therapies. This comes at a time when abdominal pain is one of the major reasons American patients visit the emergency room (ER). Caring for abdominal pain is characterized by a high chance of misdiagnosis unlike other health issues. ER doctors are faced with challenging and time-consuming processes when trying to determine the actual cause of abdominal pain. This is a case study of a woman who visited an emergency room for severe abdominal pain and was diagnosed with diverticulitis. The case study entails an analysis of SOAP (Subjective, Objective, Assessment, and Plan) factors in describing abnormal findings relating to the woman’s condition.

Case Analysis

Diagnosis of a patient’s abdominal pain or cramping is a complex process that requires consideration of various factors that could be contributing to the pain. In this case study, information regarding the patient’s abdominal pain has been provided using the SOAP framework. This framework is commonly used in clinical settings to help describe abnormal findings relating to a patient’s condition. For this case study, SOAP was utilized to help identify abnormal issues relating to the individual’s abdominal pain. The information provided through this technique can be utilized to help nurses prepare themselves to better diagnose conditions in the abdomen. This use of this technique in abdominal assessment also involved collecting information regarding the patient’s history as well as conducting physical examinations and diagnostic tests.

Subjective Portion of the Note

An important part in accurate diagnosis of a patient...

According to Macaluso & McNamara (2012), collection of the patient’s history should incorporate a complete description of his/her pain as well as medical, social, and surgical information. Based on the subjective portion of the note provided relating to this patient’s condition, the patient’s history, medical, and social information was collected. Additionally, the subjective portion of the note provides a description of the extent of abdominal pain. However, the description does not include information regarding the exact location of the abdominal pain, its associating symptoms, and aggravating factors. Therefore, additional information that should be included in the subjective portion of the note include the precise location of the pain, its associating symptoms, alleviating factors, and aggravating factors. Such information is usually critical when describing a history of the present illness (HPI) and helps in determining a proper diagnosis for the condition.
Objective Portion of the Note

The objective portion of the note provides information relating to the vital signs of the patient’s abdominal pain. Moreover, the clinician has also included information about the individual’s physical assessment results under the objective section. However, the subjective portion of the note lacks some important information that would help in proper diagnosis of the patient’s situation. Some additional information that should be included in the documentation under the objective section include physical assessment results relating to eyes, ears, nose, throat or mouth, lymph nodes, and extremities. This information is essential to help in understanding the associated symptoms of the abdominal pain as well as its alleviating or aggravating factors, which is vital during diagnosis.

Assessment

Based on information from the subjective and objective portions of the note,…

Cite this Document:
Copy Bibliography Citation

Related Documents

Assessment of Abdominal Pain
Words: 995 Length: 3 Document Type: Peer Reviewed Journal

Abdominal AssessmentA 65-year-old African American presents to the emergency department with a two days history of intermittent epigastric abdominal pain radiating from the back. Following an assessment, he was diagnosed with abdominal aortic aneurysm (AAA) but the doctor ordered a CTA scan. However, diagnosis of abdominal pain is a time-consuming and challenging process that can result in misdiagnosis if not conducted properly. The doctor�s recommendation of a CTA scan is

Nurses and Abdominal Pain Patient Care the
Words: 1314 Length: 4 Document Type: Essay

Nurses and Abdominal Pain Patient Care The people that make up a medical setting contribute immensely and provide the professional care they know to patients who visit the place, whether it's a clinic or a hospital. When the patient first walks in, he or she will meet the desk clerk and other people who will help her get settled in. However, none are the most important when it comes to first

Acute Abdominal Pain -- Assessment Nurses Are
Words: 870 Length: 3 Document Type: Essay

Acute Abdominal Pain -- Assessment Nurses are very often the first medical aid providers that most patients see. In today's interprofessional healthcare set up, a nurse's approach in collecting a patient's history and diagnosing if the pain is acute or non-acute would assuredly help in providing the patient with appropriate treatment. It is therefore primary that nurses be fully equipped to diagnose the various ailments and start on the care to

Lower Abdominal Pain
Words: 705 Length: 2 Document Type: Essay

Lower Abdominal Pain Patient: Patient is a 30-year-old female presenting with lower abdominal pain, beginning approximately 48-hour previous to her exam. Over the last few days, her pain has increased, and she reports vaginal bleeding that is scanty. She did have a normal menstrual period that ending two-weeks prior, and she indicates this was normal and lasted about 4 days. She is Gravida 2, Para -0, Miscarriage -- 2, and has

Pain Management in Post-Operative Patients Pain Suffered
Words: 2524 Length: 8 Document Type: Essay

Pain Management in Post-Operative Patients Pain suffered patients undergoing surgery. The severity pain vary patient. It nurse caring patient postoperative phase manages patient's pain. Questions arise pain assessment, nurses estimation mismanagement patient pain, modes administration medical orders pain management suitable. Pain Management in Post-Operative Patients Effective pain control in post-operative patients is essential in ensuring patient's quick recovery, earlier mobilization and lower cost and higher patient satisfaction. The immune system of patients who

Pain Is the Most Famous Member of
Words: 3217 Length: 10 Document Type: Essay

Pain is the most famous member of bodily feelings including orgasms, tickles, itches and tingles among others. These feelings are normally attributed to the locations of the body and seem to have several features like duration, intensity and volume which are attributed to quantities or physical objects. For most patients seeking for clinical help, pain is often the most common problem and the most common nursing diagnosis. Generally, pain can

Sign Up for Unlimited Study Help

Our semester plans gives you unlimited, unrestricted access to our entire library of resources —writing tools, guides, example essays, tutorials, class notes, and more.

Get Started Now