Assessment of the Gastrointestinal System

You will perform a history of an abdominal problem that your instructor has provided you or one that you have experienced and perform an assessment of the gastrointestinal system. You will document your subjective and objective findings, identify actual or potential risks, and submit this in a Word document to the drop box provided.

Remember to be objective when you document; do not make judgments. For example, if the person has a palpably enlarged liver, do not write “the liver is enlarged probably because they drink too much.” Avoid stating that something is normal but instead state WHY you think it is normal. For example, if you think that the abdomen looks “normal” – which is subjective – then document that the “abdomen is flat, skin color consistent with rest of body, no lesions, scars, bulges, or pulsations noted.” Assessment of the Gastrointestinal System

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Gastrointestinal System Assignment

Submit your completed assignment by following the directions linked below. Please check the Course Calendar for specific due dates.

Title:

Documentation of problem based assessment of the gastrointestinal system.

Purpose of Assignment:

Learning the required components of documenting a problem based subjective and objective assessment of gastrointestinal system. Identify abnormal findings.

Course Competency:

Prioritize appropriate assessment techniques for the gastrointestinal, breasts, and genitourinary systems.

Instructions:

Content: Use of three sections:

Subjective
Objective
Actual or potential risk factors for the client based on the assessment findings with description or reason for selection of them.

Format:

Standard American English (correct grammar, punctuation, etc.)

Resources:

Chapter 5: SOAP Notes: The subjective and objective portion only

Sullivan, D. D. (2012). Guide to clinical documentation. [E-Book]. Retrieved from http://ezproxy.rasmussen.edu/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=nlebk&AN=495456&site=eds-live&ebv=EB&ppid=pp_91 >

Smith, L. S. (2001, September). Documentation do’s and don’ts. Nursing, 31(9), 30. Retrieved from http://ezproxy.rasmussen.edu/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=rzh&AN=107055742&site=eds-live

Documentation Grading Rubric- 10 possible points

Levels of Achievement
Criteria	Emerging	Competence	Proficiency	Mastery
Subjective (4 Pts)	Missing components such as biographic data, medications, or allergies. Symptoms analysis is incomplete. May contain objective data.	Basic biographic data provided. Medications and allergies included. Symptoms analysis incomplete. Lacking detail. No objective data.	Basic biographic data provided. Included list of medications and allergies. Symptoms analysis: PQRSTU completed. Lacking detail. No objective data. Information is solely what “client” provided.	Basic biographic data provided. Included list of medications and allergies. Symptoms analysis: PQRSTU completed. Detailed. No objective data. Information is solely what “client” provided.
Subjective (4 Pts)	Points: 1	Points: 2	Points: 3	Points: 4
Objective (4 Pts)	Missing components of assessment for particular system. May contain subjective data. May have signs of bias or explanation of findings. May have included words such as “normal”, “appropriate”, “okay”, and “good”.	Includes all components of assessment for particular system. Lacks detail. Uses words such as “normal”, “appropriate”, or “good”. Contains all objective information. May have signs of bias or explanation of findings.	Includes all components of assessment for particular system. Avoided use of words such as “normal”, “appropriate”, or “good”. No bias or explanation for findings evident Contains all objective information	Includes all components of assessment for particular system. Detailed information provided. Avoided use of words such as “normal”, “appropriate”, or “good”. No bias or explanation for findings evident. All objective information
Objective (4 Pts)	Points: 1	Points: 2	Points: 3	Points: 4
Actual or Potential Risk Factors (2 pts)	Lists one to two actual or potential risk factors for the client based on the assessment findings with no description or reason for selection of them. Failure to provide any potential or actual risk factors will result in zero points for this criterion. Assessment of the Gastrointestinal System	Brief description of one or two actual or potential risk factors for the client based on assessment findings with description or reason for selection of them.	Limited description of two actual or potential risk factors for the client based on the assessment findings with description or reason for selection of them.	Comprehensive, detailed description of two actual or potential risk factors for the client based on the assessment findings with description or reason for selection of them.
Actual or Potential Risk Factors (2 pts)	Points: 0.5	Points: 1	Points: 1.5	Points: 2

Clients Presentation:

Alex Smith, a 24-year-old African American male presenting with GI distress.

He states he has emesis, loose stool, and upper right abdomen pain. The Patient reports symptoms started two days ago after eating grilled chicken for lunch. The Patient reports that he vomited four times in the last four hours and has had multiple bowel movements since the symptom started and the most recent of which occurred an hour ago. Stools reported being brown and of a liquid consistency, and vomit was described as a greenish-yellow tint. He describes the pain as sharp and burning and claims it is primarily felt in the upper left quadrant of his abdomen. On a scale of 1 to 10, the pain was rated as 6. The patient claims that eating causes intense pain and that lying down reduces the pain to a level of 4 on a scale of 1 to 10. He adds that he is feeling nauseous, fatigued, and anxious and stated that his appetite has decreased and had been on a liquid diet for the past 24 hours due to his nausea. He denies any recent travels or weight changes. The Patient states that he is currently taking Tylenol as needed for pain management and prescriptions for Thiamine, Vitamin B, and Folate supplements medications. He reports being allergic to Penicillin. He reports being an alcoholic since he was 22 but does not smoke cigarettes. His respirations are 16, BP 170/90, Temperature is 99.9. His weight is 90.9 kg, down from 95.5kg (from last checkup). He claims no history of GI problems, but his mother had a history of peptic ulcers, and his father died of a heart attack. Assessment of the Gastrointestinal System

Subjective Data (4 points):

Objective Data (4 points):

Describe 2 Actual/Potential Risk Factors ( 2 points):

Assessment of the Gastrointestinal System