Week 5 iHuman Self-Reflection
Jessica Lindner
Chamberlain University
NR 509 Advanced Physical Assessment
Dr Ashlee Loewen
August 2022
lOMoAR
... [Show More] cPSD|24448587
Week 5 iHuman Self-Reflection
D.J. is a 54 y.o. female with c/o abdominal pain. The NP should ask questions to identify
onset, location, characteristics, radiation, factors that make it better or worse, and any related
medical, surgical, or social factors (Bickley, et. al., 2021). Using the OLDCARTS model I asked
questions to discover the pain was aching/cramping, started 3 days ago after dinner, comes on
quickly and was getting worse. I then asked about additional concerns the patient was
experiencing to find out she was also having vomiting and constipation. Pertinent health history
related to abdominal complaints includes past abdominal surgeries or Cesarean deliveries,
medical history including digestive system disease or type 2 diabetes, family history of digestive
disease, travel history outside of the United States, recent hospitalizations, and medication use,
particularly the use of antibiotics, laxatives, and opioids (Bickley, et. al., 2021). Through similar
questioning as used to discuss the abdominal pain, I was able to find out that vomiting started
yesterday, was a greenish liquid, caused by eating. Related to the constipation, the patient
reported a hx of constipation and her last BM was 2 days ago. To rule out an infectious process I
inquired about any recent refers, infections or wounds which the patient denied.
The presentation of acute mid-abdominal pain, distention, nausea/vomiting, constipation,
and inability to pass gas is consistent with a small bowel obstruction (SBO) (Bickley, et. al.,
2021). Abdominal surgeries significantly increase the risk for a SBO secondary to post-surgical
adhesions, so I reviewed the patient’s surgical history. She in fact had a hx of 2 prior abdominal
surgeries including gallstone removal 15 years ago and female fibroid removal 2 years ago,
therefor she had a significantly increased risk for developing a SBO. In addition to the health
history and review of systems, I used physical assessment and diagnostics to confirm my
diagnosis of a SBO. On assessment the abdomen was mildly obese and visibly distended. Mild
lOMoAR cPSD|24448587
discomfort was present throughout general abdomen, occasional palpable peristalsis and
moderately tympanic percussion. Abdominal distension, nausea and vomiting, and hypoactive
bowel sounds are all findings related to the epigastric abdominal pain (Bickley, et. al., 2021).
Diagnostically, the abdominal XR confirmed the suspicion of a small bowel obstruction and UA
showed high specific gravity suggestive of mild dehydration. Through detailed health history,
ROS, physical assessment and diagnostic testing I was able to effectively diagnose the patient
with a SBO and get them the care they needed to recover with good health outcomes. [Show Less]