Focused Exam: Abdominal Pain Results | Turned In
Introduction to Health Assessment - Spring 2020, NURS 3293
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Overview
Subjective Data Collection: 38 of 41 (92.7%)
Transcript
Subjective Data Collection
Hover To Reveal... Indicates an item that you
Objective Data Collection found.
Hover over the Patient Data items Indicates an item that is
Education & Empathy below to reveal important available to be found.
information, including Pro Tips and
Documentation
Example Questions.
Care Plan
Self-Reflection
Category Scored Items Patient Data
Not Scored
Experts selected these topics as essential components A combination of open and closed questions will yield
of a strong, thorough interview with this patient. better patient data. The following details are facts of t
patient's case.
Chief Complaint
Established chief complaint Reports abdominal pain
Reports difficulty with bowel movements
Orientation
Asked about orientation Oriented to own person
Oriented to place
Oriented to situation
Oriented to time
History of Presenting Illness
Asked about onset of the pain Reports discomfort for the past five days
Reports pain worsened intensely 2-3 days ago
Asked about location of the pain Reports pain in lower abdomen
Reports pain is not localized
Denies flank pain
Asked about pain rating on a scale Reports current pain rating of 2/10
Reports pain at its lowest is 2/10
Reports pain at its worst is 8/10
Asked about characteristics of the pain Describes pain as dull
Describes pain as cramping
This study source was downloaded by 100000869052700 from CourseHero.com on 07-17-2023 15:11:45 GMT -05:00
Asked about aggravating factors Reports pain is aggravated by eating
Reports pain is aggravated by physical activity
Asked about impact of pain on daily life Reports recent difficulty participating in usual
activities
Reports low energy
Followed up on constipation Reports current constipation
Reports constipation all of last 5 days
Asked about diarrhea Reports recent diarrhea
Followed up on diarrhea Reports diarrhea about six months ago
Reports diarrhea had a sudden onset
Reports diarrhea lasted one day
Asked about substances in stool Denies mucus in stool
Denies blood in stool
Asked about urination Reports slight decrease in frequency of urination
Reports darker urine recently
Denies blood in urine
Asked about fluid intake Reports decreased thirst
Reports decreased fluid intake for the last few
days
Typical fluid intake is 1-2 glasses of water a day
Denies drinking caffeinated drinks such as coffee
or soda
Past Medical History
Asked about history of constipation Denies history of constipation
Asked about typical bowel movements Reports typically having a bowel movement almost
every day
Reports typical stools are brown
Reports typical stools are formed
Reports typical stools are soft
Asked about allergies Reports latex allergy
This study source was downloaded by 100000869052700 from CourseHero.com on 07-17-2023 15:11:45 GMT -05:00 Denies medication allergies
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