Nur-320 Case Study: Patient Centered Assessments

Case Study Module 6

Patient-Centered Assessments

Southern New Hampshire University

NUR-320

Sarah Davison

March 17, 2015

Scenario: An emergency department nurse is caring for a 44-year-old woman with LLQ abdominal pain and is brought to the emergency department by her husband. Explain what type of assessment is most critical for this patient, providing a rationale for your response. Discuss the questions the nurse would ask, prioritizing these questions from most concerning to least concerning. Use your Jensen (2014) text to support your rationale. Submit your completed assignment here.

Case Study Module 6

Abdominal pain accounts for 5% of all emergency department (ED) visits and

is an important and challenging component of emergency medicine practice in all centers (Diekmann, n.d). The clinical evaluation, diagnostic workup and disposition of patients with acute abdominal pain vary significantly, depending upon the initial history and physical assessment. Before acuity level can be determined, subjective information including pain characteristics and objective information such as vital signs need to be collected followed by physical assessment of the abdomen (Diekmann, n.d).
Subjective and Objective Data
The location of pain is a useful starting point and will guide further evaluation (Hammond, 2010). In the above case scenario, a 44 year old female has a chief complaint of left lower quadrant (LLQ) pain. Pain location and characteristics are the most critical information when treating abdominal pain. To obtain a complete pain assessments consider using the OPQRST mnemonic:
• Onset: What were you doing when it started? Did the pain come suddenly or gradually?
• Provocative or palliative: Does the pain move around? Is the pain related to any bodily function such as eating, bowels, position, or exertion? Does anything lessen the pain?
• Quality: Can you describe the pain? Does it come and go? Is it constant? Is it sharp, dull or burning?
• Region and radiation: Where do you feel the pain and does it radiate?
• Severity: Can you rate your pain on a scale of 1-10?
• Timing: Can you tell me when the pain started? Have you ever had this pain before? (Jensen, 2015)
Rational: Pain is usually more serious if it began abruptly (Gerber, 2002). Observing a patient's position provides clues to pain severity. If the patient appears fairly comfortable and moves around at will, the pain is probably not severe; whereas, positions of concern would include a patient that is holding rigidly still, or guarding (Gerber, 2002). Using the OPQRST mnemonic will help determine if the presenting condition is emergent.
Although location of abdominal pain guides the initial evaluation, associated signs and symptoms are predictive of certain causes of abdominal pain and can help narrow the differential diagnosis (Cartwright, 2008). The following questions will aid in narrowing differential diagnosis:
• Have you been running a fever?
• Do you have nausea and vomiting and/ or diarrhea?
• When was your last bowel movement?
• Have you noticed any black stools or blood in your stool?
• Have your stools been clay color?
• Have you had any vaginal discharge?
• Have you had any menstrual irregularities?
Rational: Associated symptoms often allow a further focus of differential diagnosis. Symptoms associated with abdominal pain that are suggestive of surgical or emergent conditions include fever, protracted vomiting, and evidence of gastrointestinal blood loss (Cartwright, 2008). Black or bloody stool would be indicative of bleeding in the gastrointestinal tract; clay colored stools is associated with biliary system problems. Vaginal discharge or menstrual irregularities accompanied with LLQ pain may be associated with ovarian torsion or ectopic pregnancy (Cartwright, 2008).
Prior medical and surgical histories:
Past health history includes an assessment of medical and surgical problems along with treatment and course (Jensen, 2015 p.33).
• Have you had any previous treatments or hospitalizations for gastrointestinal (GI) problems?
• Have you had any abdominal surgeries? If so, what was the procedure and what was the outcome of the procedure?
• Do you have a history of ulcers, liver issues, gallbladder issues, colitis, hernias, or diverticulosis?

(Jarvis, 2012).

• Have you had any recent trauma or injury to you abdomen?

Rational: History of hospitalizations for GI problems may reveal an exacerbation of a previously diagnosed condition (Jensen, 2015). Abdominal surgeries increase risk for adhesions, infections, obstructions, and malabsorption (Jensen, 2015).

Physical Assessment

After obtaining vital signs, a physical assessment would include inspection, auscultation, percussion and palpation of the abdomen. Inspection consists of visual examination of the abdomen noting its shape, skin abnormalities, abdominal masses, and the movement of the abdominal wall with respiration (Walker, 1990). Abnormalities detected on inspection combined with the patient’s history provide clues to intra-abdominal pathology (Diekmann, n.d). Auscultation of the abdomen is performed before percussion and palpation which can alter bowel motility (Jensen, 2015). Auscultation allows detection of altered bowel sounds, rubs, or vascular bruits. Normal peristalsis creates bowel sounds that may be altered or absent by disease. Percussion is performed to identify organ size and detect the presence of fluid, gas or masses. Palpation includes both light and deep techniques (Jensen, 2015). Light palpation detects areas of tenderness, distention, ascites, presence of masses, and bladder distention; whereas deep palpation, an advanced skill assesses

for masses, tenderness, and rigidity (Jensen, 2015). Left lower quadrant tenderness is usually due to sigmoid diverticulitis but can be related to bacterial, parasitic or viral infections, celiac disease, chronic constipation, food intolerance such as lactose intolerance, inflammatory bowel disease (Crohn’s disease and ulcerative colitis), irritable bowel syndrome (Jensen, 2015).
Conclusion
Effective triaging involves careful listening, accurate history-taking and a thorough abdominal assessment (Diekmann, n.d). A stepwise approach to abdominal pain requires identification of specific signs and symptoms. The left lower quadrant pain focuses on evaluation for diverticulitis. Fever, previous diverticular disease, or suggestive physical examination findings (e.g., distention, tenderness, rectal blood) should prompt empiric therapy (Cartwright, 2008). A normal evaluation should prompt further consideration of urinary or gynecologic pathology (Cartwright, 2008).
References
Cartwright, MD, S., & Knudson, MD, M. (2008, April 1). Evaluation of Acute Abdominal Pain in Adults. Retrieved March 16, 2015, from https://www.med.upenn.edu/gastro/documents/AmFamPhysacuteabdominalpain.pdf
Diekmann, MD, R.

(n.d.). ABDOMINAL PAIN. Retrieved March 15, 2015, from http://sfghed.ucsf.edu/Education/Lectures/Syllabus/AbdominalPain.pdf

Gerber Zimmermann, P. (2002, December 1). Triaging lower abdominal pain. Retrieved March 16, 2015, from http://www.modernmedicine.com/modern-medicine/content/triaging-lower-abdominal-pain?page=full

Hammond, MD, N., Nikolaidis, MD, P., & Miller, MD, F. (2010). Left Lower-Quadrant Pain: Guidelines from the American College of Radiology Appropriateness Criteria. Am Fam Physician, 82((7)), 766-770.

Jarvis, C. (2012). Abdomen. In Physical examination & health assessment (6th ed.). St. Louis, Mo.: Elsevier/Saunders.

Jensen, S. (2015). Abdominal Assessment. In Nursing health assessment: A best practice approach (Edition 2. ed.). Philidelphia, PA.Wolters Kluwer.

Left Lower Quadrant Pain - Symptoms, Causes, Treatments - Causes. (2014, June 26). Retrieved March 15, 2015, from http://www.healthgrades.com/right-care/digestive-health/left-lower-quadrant-pain--causes

Walker, H. (1990). Chapter 93Inspection, Auscultation, Palpation, and Percussion of the Abdomen. In Clinical methods: The history, physical, and laboratory examinations (3rd ed.). Boston:

Butterworths.