Nursing

Thank you for receiving my order this is the abdominal problem scenario that you can use to write the assignment. 55-year-old male reported vomiting and diarrhea after returning from vacation in Taiwan. He stated that he had roast pork for dinner last night and went drinking with friends.

ANSWER

Documentation of Problem Based Assessment of the Gastrointestinal System

Subjective

The patient is a 55 year old male who reported to the hospital due to abdominal pain. The patient reported of vomiting and diarrhea after returning from a vacation in Taiwan. The patient had a roast port for dinner the previous night and went drinking with friends. The patient does not take any medications. The patient rates his abdominal pain at 8 out of 10. The patient states that the pain, vomiting and diarrhea stated this morning. The patient seems a normally healthy adult and denies of other medical issues.

Objective

During the physical examination the contour of the patient’s abdomen was examined. The normal contour of the abdomen is typically rounded and flat. After the examination, the patient had a concave contour which makes the abdomen look sunken. The umbilicus was inverted and midline with no signs of discoloration. The patient had a smooth skin with homogenous color. The patient has bow sounds hyperactive on all quadrants, abdomen protuberant, palpation and tenderness. No costovertebral tenderness noted on palpation.  The hyperactive bowel sounds in all the four quadrants occurred less than 1 minute after examination. Upon palpation, the patient complained of pain in the right upper and lower quadrants.

Actual or Potential Risk Factors

Appendicitis is one of the major potential factors due to the lower abdominal pain. Specifically, pain in the lower right abdomen may be linked to inflammation. Appendicitis occurs due to inflammation of the appendix or filling with pus (Alvarado, 2018). Blockage of the large intestines or various infections such as bacteria in the digestive tract can cause appendicitis. The symptoms of appendicitis align with the patient’s condition since the abdominal pain begins at the right side of the lower abdomen and is experiencing vomiting.

Another potential risk factors could be Peritonitis which is the inflammation of peritoneum. The silk like membrane that lines the inner abdominal wall inflates due to bacterial or fungal infection (Ross, Matthay and Harris, 2018). Peritonitis symptoms align with the patient condition abdomen tenderness, abdominal pain getting intense with touch or motion, vomiting and diarrhea. The pain experienced during palpating is an abnormal finding since the patient experiences pain in the lower right quadrant where the appendix is located.

References

Alvarado, A. (2018). Clinical approach in the diagnosis of acute appendicitis. Garbuzenko D. Current Issues in the Diagnostics and Treatment of Acute Appendicitis. Intech Open, 13-42.

Ross, J. T., Matthay, M. A., & Harris, H. W. (2018). Secondary peritonitis: principles of diagnosis and intervention. Bmj, 361.