System Jenna Simpson, 24 years old Suggested GI/GUNursing Assessment Skills
Demonstrated: GI/GU:Inspection:skin (coloration, vascularity, striae, scars, lesions, rashes)
•Contour –(flat, rounded, scaphoid, protuberant/distended)
•Umbilicus –contour•Symmetry (relaxed, supine position)
•Abdominal movement during breathing
•Aortic pulsationsAuscultation: (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 with bell. Percussion:
•Percuss for tonein a systematic fashion to all quadrants•Percuss liver span
•Dull percussion to liver and kidney (costovertebral angle –12thrib)
•Tympany to other parts of the abdomenPalpation:
•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•Palpate liver
•Palpate spleen•PalpatekidneysMake 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 promotelearning by having students identify what they do not yet know and guidewhere they can find the information in the textbook or on the internet to address knowledge gaps. Thisis educational best practice and another way to scaffold knowledge!
© 2019Keith Rischer/www.KeithRN.comPresent Problem:Jenna Simpson is a 24-year-old Caucasian femalewho weighs 210 pounds (95.5 kg-BMI of 36.5)who presents to the emergency departmentwith sudden onset of sharp pain inthe right side of herlower back that radiates tothe right sideof her abdomenand into her groin.
The pain started tenhours ago, but lasted only 15 minutes and then went away. She took ibuprofen 600 mg PO an hour ago but has not helped,andthe pain persists.
She statesthat this pain is different than when she has epigastric pain because of gastroesophageal reflux disease (GERD).
She feels nauseated but has not vomited. Jenna appears uncomfortable and pleads with the triage nurse, “do something to get rid of this pain!
What is wrong with me?
”What data from the present problemare RELEVANT and must be interpreted as clinically significant by the nurse?
(Reduction of Risk Potential)RELEVANT Data from Present Problem:
Clinical Significance:What is the RELATIONSHIP of your patient’s past medical history (PMH) and current meds?
(Which medication treats which condition? Draw lines to connect.)PMH:Home Meds:Pharm.
Class:Mechanism of Action (own words):AnxietyGastroesophageal reflux disease (GERD)Alprazolam 0.5 mg PO every 8 hours PRNPantoprazole 10 mg PO BIDPatient Care Begins:What vital signs are abnormal?
What is thereason(pathophysiology) for these findings?
(Reduction of Risk Potential/Health Promotion and Maintenance)AbnormalVS:Clinical Significance:Current VS:P-Q-R-S-T Pain Assessment:T: 98.9 F/37.2 C(oral)Provoking/Palliative:Nothing changes the levelof painP:92(regular)Quality:Sharp, severeR: 28(regular)Region/Radiation:
Right back/flank that radiates into RLQ and groinBP:148/84Severity:10/10O2 sat:99% room airTiming:Constant the past hourJenna is quickly brought to a room.
Youare the nurse andquickly collect the following assessment data:
© 2019Keith Rischer/www.KeithRN.
What assessment findings are abnormal? Whatis thereason (pathophysiology) for these findings?
(Reduction of Risk Potential/Health Promotion & Maintenance)RELEVANT Assessment Data:Clinical Significance:
Put it All Together and Think Like a Nurse!1.Interpreting relevant clinical data, what is the most likely primary problem?
What body system(s) will you assess most thoroughly based on the primary/priority concern?
What’s the problem?What’s causing the problem?(explain pathophysiology in OWN words)PRIORITY Body Systemto Assess:Current
Assessment:GENERAL APPEARANCE:Obesefemaleissitting upright in bed.Alert, oriented, , in moderate distress, dress appropriate for the season, hygiene and grooming normalfor age and gender, anxious, body tense, +grimacing, appears to be uncomfortable.
RESP:Breath sounds clear on inspiration and expiration in all lobes anteriorly, posteriorly, and laterally,with equalaeration bilaterally ant/post, nonlabored respiratory effortwith + tachypneic.Posture erect, sitting in bed, in moderate distress, on room air, AP diameter 1:2, symmetryof the thoracic cavity noted with inspiration and expirationCARDIAC:
Pink,warm & dry, no edema, heart sounds regular with no abnormal beats, pulses strong, equal with palpation at radial/pedal/post-tibial landmarks, briskcap refill, carotid pulse 3+ and regular bilaterally. Heart tones audible and regular, S1 and S2,noted over the 5cardiac landmarkswith no abnormal beats or murmurs. No JVD noted at 30-45 degrees.
NEURO: Alert & oriented to person, place, time, and situation (x4); muscle strength 5/5 in both upper and lower extremities bilaterally.
GI:Abdomen flat, soft, bowel sounds audible per auscultation in all four quadrants, nontenderto gentle palpation in all four quadrantsGU:Voiding without difficulty, dark amber/rustycolor with recentvoid to collect urinespecimen
INTEGUMENTARY: Skin warm, dry, intact, normal color for ethnicity. No clubbing of nails, cap refill <3 seconds.Hair short, brown, soft. Hair distribution normalfor age and gender. Skin integrity intact, skin turgor elastic, no tenting present © 2019Keith Rischer/www.KeithRN.com2.Which specific nursing assessments for this body system are most important?
Validate successful completion of each nursing assessment on a manikin (if available) identified with peer or faculty initials.
PRIORITY Nursing Assessments:
Rationale:Validate Student Performance:
3.What is the current nursing priorityand plan of care? Nursing PRIORITY:PRIORITY Nursing Interventions:Rationale:Expected Outcome:
4.State the rationale and expected outcomes for the medical plan of care. Medical Management:Rationale:Expected Outcome:Establish peripheral IVHydromorphone 1 mg IVPKetorolac 15 mg IVPOndansetron 4 mg IVPRadiology Reports:
What diagnosticresults are RELEVANT and must be interpreted as clinically significant by the nurse?
(Reduction of Risk Potential/Physiologic Adaptation)Radiology: CT PelvisResults:Clinical Significance:4 mm stone in the distal right ureter © 2019Keith Rischer/www.KeithRN.comLab Results: Urinalysis + UA MicroColor:Clarity:Sp.
What lab results are RELEVANT and must be recognized as clinically significant by the nurse?
(Reduction of Risk Potential/Physiologic Adaptation)RELEVANT Lab(s): Clinical Significance:Complete Blood Count (CBC)WBCHGBPLTs% NeutsBandsCurrent:10.214.2285720RELEVANT Lab(s)
: Clinical Significance:Evaluation: Thirty Minutes Later…Current VS:Most Recent:Current PQRST:T: T: 98.9 F/ 37.2 C(oral)Provoking/Palliative:P: P:92(regular)Quality:R: R: 28(regular)Region/Radiation:BP:
BP:148/84Severity:O2 sat:O2 sat:99% room airTiming:Evaluate the response to nursing and medical interventions.
All orders have been implemented.What would be the EXPECTED response inclinical data collected ifher pain and anxietyare decreased?
© 2019Keith Rischer/www.KeithRN.com1.What data is RELEVANT and must be interpreted as clinically significant by the nurse?
(Reduction ofRiskPotential/Health Promotion and Maintenance)RELEVANT VS Data:Clinical Significance:
TREND: Improve/Worsening/Stable
:RELEVANT Assessment
Data: Clinical Significance:
TREND: Improve/Worsening/
Stable:2.Has the status improved or not as expected to this point?
Does your nursing priority or plan of care need to be modified after this evaluation assessment?
(Management of Care, Physiological Adaptation)Evaluation of Current Status:Modifications to Current Plan of Care
:3.What did you learn that you can apply to future patients in yourcare? Reflect on your current strengths and weaknesses this case study identified.
What is your plan to make any weakness a future strength?
What Did You Learn?
What did you do well in this case study?
What could have been donebetter?
Current Assessment:GENERAL APPEARANCE:RESP:CARDIAC:NEURO:GI:GU:INTEGUMENTARY: