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NUR 2180 Rasmussen College Gastrointestinal System Paper

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NUR 2180

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Running head:ASSESSMENT OF THE GASTROINTESTINAL SYSTEM 1

Assessment of the Gastrointestinal System

Morris Daffa

NUR2180 Section MHQ2 Physical Assessment

Rasmussen College

Joylyn Anderson

July 25, 2020

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ASSESSMENT OF THE GASTROINTESTINAL SYSTEM 2

Assessment of the Gastrointestinal System

Objective findings

The patient is thirty-seven years old and has a history of reduced appetite and a drastic decrease

in weight. He also feels like stomach bloating and excess gas. The patient looks pale and tired

appears. He did not look healthy since he was sweating profusely. The patient mentioned a

family history of inflammatory bowel disease (Crohn's). The patient complained of bloody stool

for the previous three days. He also testifies of sharp pains in the stomach. He does not smoke

but consumes alcohol once in a while and has not taken any medication. There is no history nor

indication of a previous injury on the abdominal area and no significant past medical history that

relates to the current state. He reported three or fewer bowel movements in the current week and

firm, dry and hard poop, also experiencing aches and back pains, fever and shakes, biliousness,

and vomiting. The patient lastly traveled like three months ago and has not changed any of his

usual routines.

Subjective findings

The client seems uncomfortable but then not fatal. The skin and neck are healthy

however, he possesses a toxic fever, shudders, biliousness, and gagging. He as well complains of

severe stomach aches, blood in the stool that is difficultto pass. There is a noticeable bulk in the

upper side of the abdomen that is hard to palpate. A feeling of soreness is present at the

costovertebral position that insinuates cases of pyelonephritis. The examination at the back did

not show any abnormalities on the spine. The abdomen shows no surgical scars. Analysis of the

deep tendon reflexes, bulbocavernosus reflexes, and anal tone appeared bruised. Palpation

reveals a tender and slightly engorged kidney. The patient has a tattoo on the right side of the

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Running head:ASSESSMENT OF THE GASTROINTESTINAL SYSTEM Assessment of the Gastrointestinal System Morris Daffa NUR2180 Section MHQ2 Physical Assessment Rasmussen College Joylyn Anderson July 25, 2020 1 ASSESSMENT OF THE GASTROINTESTINAL SYSTEM 2 Assessment of the Gastrointestinal System Objective findings The patient is thirty-seven years old and has a history of reduced appetite and a drastic decrease in weight. He also feels like stomach bloating and excess gas. The patient looks pale and tired appears. He did not look healthy since he was sweating profusely. The patient mentioned a family history of inflammatory bowel disease (Crohn's). The patient complained of bloody stool for the previous three days. He also testifies of sharp pains in the stomach. He does not smoke but consumes alcohol once in a while and has not taken any medication. There is no history nor indication of a previous injury on the abdominal area and no significant past medical history that relates to the current state. He reported three or fewer bowel movements in the current week and firm, dry and hard poop, also experiencing aches and back pains, fever and shakes, biliousness, and vomiting. The patient lastly traveled like three months ago and has not changed any of his usual routines. Subjective findings The client seems uncomfortable but then not fatal. The skin and neck are healthy however, he possesses a toxic fever, shudders, biliousness, and gagging. He as well complains of severe stomach ...
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Tags: Gastrointestinal System Gastrointestinal tract illnesses GIT diseases gastrointestinal complications gastrointestinal issues