Question

Documentation Exercise Scenario: Question 56 refers to this scenario. Your shift supervisor assigns you to Kay Hudson, a.47-year-old female patient who was admitted this morning for abdominal pain and intermittent nausea of 2 days duration. She was dehy- drated and the physician ordered an IV of 1/2NS to infuse at 100 mL/hour. She began vomiting this afternoon and complain- ing of increasing abdominal pain and received an injection of pain medication just before the end of the shift. She had not voided yet when the off-going nurse gave you a report. The physician has voiced concerns that she may be obstructing her small bowel and wants an update on her status. You also have a second patient, Margaret Gruntmeir, an 81-year-old female who is confused and combative and needs to have an IV initiated so that she can be given some extra fluids. She has very poor veins and you know that it may keep you tied up for a while gathering your supplies, finding an acceptable vein, and performing the IV initiation, all the while trying to keep the patient calm and still. Your priority is to perform a focused Gl assessment along with any other pertinent assessments on Kay Hudson so you can 0 notify the physician. Then you can focus on the IV initiation for Margaret Gruntmeir. 56. Document using a nurse's note form (Figure 24-1) a narrative assessment of a focusec GI assessment and any other assessments that you consider pertinent to perform on Ms. Hudson before you can proceed with admitting Ms. Gruntmeir

Answer 1

The physician suspect it as small bowel obstruction.Collect the complaints of the client.Initiate the assessment with the Inspection. Look for abdominal distention.Inspect for the signs of dehydration due to vomiting.In palpation and percussion steps, look for obstruction , pain area, type of pain and pain score , tenderness and gas presence. Then in the auscultation , observe for the peristalsis movement.Ensure with the client regarding the passage of the flatus or stool.

It is the needed assessment to be done for the small bowel obstruction.It should be done initially and informed to the physician so that he starts with the treatment and the patient will be better.

In documentation, if the client has small bowel obstruction then she can narrate the assessment process as follows.Patient taken over from the nurse at afternoon.Patient pain has increased not responded to pain medication.Still not voided.Informed to Physician and get order to perform the assessment for small bowel obstruction. As per the order with the patient consent performed assessment. Patient dehydrated.signs of dehydration present.Pain and tenderness present in ___ (pain location in abdomen)and pain score __.(ask from client by using pain scale)Abdominal distention present. Distented to ___cm( from admission day level).bowel movement is present till ____.(the area of bowel).Intake and output chart maintained.Patient not voided. output is only in vomiting form.Patient is on IV fluids.

This assessment is sufficient and inform about the findings to the physician in before taking care of another patient.