Patient History

 

Gastrointestinal Assignment Patient Case

Patient Case- you should embellish and add additional details to the patient case as needed to reflect full documentation of a musculoskeletal problem, but please use the following basic information to document about your patient:

 

Subjective Data: Includes patient history and all other subjective data.

• Chevy, a 46-year-old Caucasian male
• Admitted diagnosis: gastrointestinal (GI) bleed.
• Medications include omeprazole, Thiamine, Vitamin B, and Folate supplements.
• Allergies to morphine, ibuprofen, and tetracycline.
• Substance use- alcohol – (might want to ask him about his alcohol intake)
• Currently: Mr. Chase reports that five minutes prior to nurse entering the room, he vomited bright red blood into the garbage can. Patient reports, “I threw up four times in the last four hours.” Patient states, “I just felt it coming on fast. I knew I shouldn’t have eaten that food…” ask him some more PQRSTU about his vomiting/abdominal system
• Pain: 4/10 – ask him some PQRSTU about the pain
• He also reports feeling nauseous, fatigued, and anxious.

Objective Data: Includes all Physical Exam (e.g., Vitals, your inspection, auscultation, percussion, and palpation results)

• Vital Signs: Oral Temp 36.5 C, HR 124 BPM, RR 24, and BP 100/62 mm Hg. SpO2 93%. Weight 55 kg (last weight 65 kg). Height: 5ft 10.08 inches
• Inspection: Abdomen distended-. Document the rest of inspection as a normal or expected findings.
• Auscultation: Bowel sounds hyperactive in all four quadrants. Document rest of auscultation exam as normal or expected findings
• Palpation: Abdomen firm and slightly tender in all quadrants. Other palpation documentation should reflect expected or normal findings

Describe Two Actual or Potential risk factors based on the assessment findings, with description or reason for selection of them

1. Chevy is at risk for…………………………………due to…………………………
2. He is also at risk for………………due to …………………………………………………….

 

Title:

Documentation of problem based assessment of the gastrointestinal system.

 

Purpose of Assignment:

Learning the required components of documenting a problem based subjective and objective assessment of gastrointestinal system. Identify abnormal findings.

 

Course Competency:

Prioritize appropriate assessment techniques for the gastrointestinal, breasts, and genitourinary systems.

 

Instructions:

 

Content:  Use of three sections:

• Subjective
• Objective
• Actual or potential risk factors for the client based on the assessment findings with description or reason for selection of them.

 

 

Format:

• Standard American English (correct grammar, punctuation, etc.)

Resources:

Chapter 5: SOAP Notes: The subjective and objective portion only

Sullivan, D. D. (2012). Guide to clinical documentation.  [E-Book]. Retrieved from http://ezproxy.rasmussen.edu/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=nlebk&AN=495456&site=eds-live&ebv=EB&ppid=pp_91 >

 

Smith, L. S. (2001, September). Documentation do’s and don’ts. Nursing, 31(9), 30. Retrieved from http://ezproxy.rasmussen.edu/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=rzh&AN=107055742&site=eds-live

 

Documentation Grading Rubric- 10 possible points

Levels of Achievement
Criteria	Emerging	Competence	Proficiency	Mastery
Subjective (4 Pts)	Missing components such as biographic data, medications, or allergies. Symptoms analysis is incomplete. May contain objective data.	Basic biographic data provided. Medications and allergies included. Symptoms analysis incomplete. Lacking detail. No objective data.	Basic biographic data provided. Included list of medications and allergies. Symptoms analysis: PQRSTU completed. Lacking detail. No objective data. Information is solely what “client” provided.	Basic biographic data provided. Included list of medications and allergies. Symptoms analysis: PQRSTU completed. Detailed. No objective data. Information is solely what “client” provided.
	Points: 1	Points:  2	Points: 3	Points: 4
Objective (4 Pts)	Missing components of assessment for particular system. May contain subjective data. May have signs of bias or explanation of findings. May have included words such as “normal”, “appropriate”, “okay”, and “good”.	Includes all components of assessment for particular system. Lacks detail. Uses words such as “normal”, “appropriate”, or “good”.  Contains all objective information. May have signs of bias or explanation of findings.	Includes all components of assessment for particular system. Avoided use of words such as “normal”, “appropriate”, or “good”.  No bias or explanation for findings evident Contains all objective information	Includes all components of assessment for particular system. Detailed information provided.  Avoided use of words such as “normal”, “appropriate”, or “good”.  No bias or explanation for findings evident. All objective information
	Points: 1	Points: 2	Points: 3	Points: 4
Actual or     Potential Risk Factors (2 pts)	Lists one to two actual or potential risk factors for the client based on the assessment findings with no description or reason for selection of them. Failure to provide any potential or actual risk factors will result in zero points for this criterion.	Brief description of one or two actual or potential risk factors for the client based on assessment findings with description or reason for selection of them.	Limited description of two actual or potential risk factors for the client based on the assessment findings with description or reason for selection of them.	Comprehensive, detailed description of two actual or potential risk factors for the client based on the assessment findings with description or reason for selection of them.
	Points: 0.5	Points: 1	Points: 1.5	Points: 2