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ABDOMINAL PAIN, DISTENSION OR DISCOMFORT

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PHYSICAL DATA

. Vital signs
. Stomach assessment which includes tenderness, soreness,
protruding, distension upon palpation and bowel noises
upon auscultation
. Digital rectal evaluation including any tenderness,
mass or hard stool
. lf vomiting, identify contents, amount and presence of
blood, examine hemoccult
. Type of pain (dull, sharp, stabbing, burning, and to rate
their pain on a scale (including whether pain is consistent
or spotty)
. Observe alleviating elements or irritating factors

HEALTH CARE HISTORY

Patient’s age and sex
Starting point, length of time frequency and intensity of symptoms
Existing medications, including any recent changes
Recent food and fluid intake habits, including any
recent variations
Current diet (typical, constrained, etc. )
All current diagnoses
Any recent laboratory or diagnostic examination outcomes
Record of relevant gastrointestinal conditions (previous
surgery, record of peptic ulcers, diverticulitis, etc. )
Approximate rate of bowel movements last bowel
movement and any connected problems

ABDOMINAL ASSESSMENT

Listen: Auscultation of the abdomen needs to
be completed prior to palpation. you want to
listen before you touch, since oftentimes
pressing the stomach can stimulate “noises”.
Listen for bowel sounds to see if they are dynamic
and audible in all four quadrants. Position the bell
of the stethoscope gently over each of the 4
quadrants. Ask the individual not to talk. Listen until
you hear recurrent gurgling or bubbling noises
once in each quadrant. Express sounds as
typical, hyperactive, hypoactive, absent. It may
require about 5 minutes to hear bowel noises.

Look: Examination is the visible assessment of the
abdomen. Look for changes to the abdomen
such as distension, bruising, rashes, coloring, scars,
pulsations, symmetry. If you notice bruising, look
at patient’s history to see if she/he is receiv: ing
heparin or insulin injections. Scars reveal
evidence of previous surgery treatment or injury.

Feel: Palpation is pressing the area. Lightly
palpate over each one of the 4 abdominal
quadrants. Note if the abdomen is soft or firm.
Look for tenderness and/or ache, muscle rigidity,
heat, superficial masses and watch patient’s facial
expressions during palpation.

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