Nursing Documentation.

Learning Goal: I’m working on a health & medical question and need an explanation and answer to help me learn.

You will perform a history of an abdominal problem – irritable bowel syndrome (IBS). Perform an assessment of the gastrointestinal system. You will document your subjective and objective findings, identify actual or potential risks, and submit this in a Word document to the drop box provided.

Remember to be objective when you document; do not make judgments. For example, if the person has a palpably enlarged liver, do not write “the liver is enlarged probably because they drink too much.” Avoid stating that something is normal but instead state WHY you think it is normal. For example, if you think that the abdomen looks “normal” – which is subjective – then document that the “abdomen is flat, skin color consistent with rest of body, no lesions, scars, bulges, or pulsations noted.”

In acquiring subjective data of an abdominal/gastrointestinal examination, remember to ask about:

  • Normal bowel patterns and if there are any changes in the bowel movement. Normal bowel movement varies among individuals, and knowing what’s normal will help the nurse identify if there is a problem
  • Normal diet. Is the patient vegetarian, vegan, etc. what does she normally eat? Did he change it?
  • Other symptoms include nausea, vomiting, and flatus, any unexplained changes in weight. any significant weight loss may delay wound healing if the patient is scheduled for surgery

In acquiring objective data, follow the steps below:

  1. Inspection. Inspect the shape of the abdomen. Is it flat, round, or globular? Look for any lesions or scarring and ask the patient what is normal for him to help differentiate what is not normal.
  2. Auscultation. It is important to do auscultation before any manual examination is done on the patient. This is to avoid any movement that may alter the auscultation result. Listen for bowel sounds and determine if it’s normal.
  3. Percussion. Percuss and determine if the abdomen is tympanitic. Also, determine if the liver size is normal by percussing to the liver edge and determining the size.
  4. Palpation. Look for rigidity or guarding. Also, look for masses, if warranted.
  5. Save your assignment as a Microsoft Word document.


Style: APA

Number of Words: 400 words

References: 1

Please Review the Explanation and answer below.


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