Adult Nursing Lecture 1

Honelako gehiago

SOAP Notes in MSD and orthopedic injury.

by Jalal Nasir

Marfan Disease

by Christopher Pereira

headache Concept map

by kellyanne fontaine

SOAP Notes in MSD and orthopedic injury.

by Jalal Nasir

Adult Nursing 2 Nursing assessment of the GI function

Summary

To facilitate the diagnostic process by adequately preparing the client

Systematic assessment can lead to prompt diagnosis and treatment

Diagnostic tests

Physical assessment

comprehensive history taking

Indigestion

Excessive gas? Belching, abdominal bloating, flatus

Beans(legumes), cabbage, milk(in lactose deficient persons) are some examples

Enquire abt food that seem to bring on these symptoms

It is impt to find out what your client means

heart burn, burning/ warmth sensation felt retrosternally and may radiate

Pay attention to what brings on the discomfort and what relieves it

Common complaint associated with eating

Diagnostic test

Endoscopic studies

Endoscopic Retrograde Cholangio-Pancreatography (ERCP)

Proctoscopy/ Sigmoidoscopy

OGD

Radiographic studies

Barium meal OR barium enema

Stool studies

Stool characteristic

Consistency

Odour

Color

Blood studies

FBC to check for WBC to determine infection

Urine studies

Sequence of question

Health history should include information affecting the client's daily function or activities of daily living

Ask abt life-style,diet, work history and types of fluid intake

Enquire abt surgeries, family history

May affect digestion, weight

Enquire abt the current GI status

Any changes in weight/appetite/chew/swallow/taste/pain,medications for 'stomach', dentures, oral hygiene,food allergy

Analyse the presenting complaint by asking more specific questions

Characteristics, onset, severity, precipitating factors, relieving factors, associated symptoms, timing

What are the common symptoms

Abdominal pain

Summarise

Time

Score

Radiation

Quality of pain

Persistent pain

After getting a history of the pain in the patient's own words, ask

Any symptoms associated with the pain? In what sequence?

What worsens/ relieves the pain?

When did it begin? How long it lasted?

What is the pain like? ache? cramp?

When did it begin? How long does it lasted?

How severe(bad) is the pain? Bearable? Interfere with activity?

Where does it start? Does the pain travel anywhere

patient to show where is the pain

3 broad cat. to abd. pain

Referred pain (distant pain when the original pain site is severe

Parietal pain (r/t inflammation, more severe than visceral pain)

Visceral pain (r/t stretching of organs)

Swallowing difficulty

Ask your client

Does your client have any medical conditions associated with the oesophagus?

What brings it on - solid foods, softer foods? Has the dysphagia pattern changes?

when did it start, is it intermittent or persistent

Where is the dysphagia felt

Dysphagia

Feelings are usually associated with swallowing and can arise from disorders of the oesophagus

Refersto difficult in swallowing and may be described as sticking, hesitating or food 'won't go down' properly

Inspection, Auscultation, Percussion and palpation

Urinary system

What info do I need to know more abt pt?

Diagnose the problem

Investigation

Health history(Interview)

Life-style

Coping stress

Work

Sleep-rest

Elimination

Activity-Exercise

Nutrition

Psychosocial factors

Family history

Past medical history

Chief complaint & present complain

Physical Examination

Subtopic