Assessment & Reasoning GI System Peggy Scott, 48 years old Suggested GI/GU Nursing Assessment Skills to Be Demonstrated: GI/GU: Inspection: skin
... [Show More] (coloration, vascularity, striae, scars, lesions, rashes) • Contour from 2 angles – (flat, rounded, scaphoid, protuberant/distended) • Note symmetry, color, veins, lesions, scars, hair distribution • Umbilicus – contour; Note: inguineal or umbilical hernias • Symmetry (relaxed, supine position) • Abdominal movement during breathing • Aortic pulsations Auscultation: (completed before palpation/percussion to not alter bowel sounds) • Bowel sounds – 1 minute per quadrant up to 5 minutes with the diaphragm • Intensity, pitch, frequency • Vascular sounds – listen for bruits in abdominal aorta with bell. Palpation: • Light palpation to all quadrants – 1 to 2 cm to detect tenderness • Deep palpation to all quadrants – 5 to 6 cm for masses (location, size, shape, pulsatility, mobility, tenderness) • Palpate bladder- light palpation ONLY; you only want to assess to see if it is distended • Check for costovertebral angle tenderness Make Learning Active! • Role play or go through the interview/body assessment process – student to student or as a group. • Review the case study as an application exercise in small groups or together as a class. • Depending on your program, some content in the case study may not have been taught. Do not let that prevent you from utilizing this case study! Use it to promote learning by having students identify what they do not yet know and guide where they can find the information in the textbook or on the internet to address knowledge gaps. This is educational best practice and another way to scaffold knowledge! Present Problem: Peggy Scott is a 48-year old African American woman who came to the emergency department because she is having severe abdominal pain radiating to the back that started 24 hours ago but has become progressively worse in the last couple of hours. She is now nauseated and states that she has “puked small amounts of green liquid” five times in the last four hours. She had two loose stools today that were dark brown or black in color. Peggy has struggled with ETOH use/abuse most of her adult life but has been sober the past six months. She begins to cry and tells the nurse that this week was the one-year anniversary of her only son’s death in an automobile accident. She reports that she has been drinking one liter of vodka daily the past week. What data from the present problem are RELEVANT and must be interpreted as clinically significant by the nurse? [Show Less]
