Assessment of the Abdomen and Gastrointestinal System Digestion, motility, and absorption are gastrointestinal system processes that supply nutrients to all cells within the body. Disruption within the GI could have effects that infiltrate other systems causing side effects outside of the digestive tract. By efficient and effective thorough documentation, the practitioner can account for all symptoms related to illness to determine possible disorder. By asking specific questions both subjectively and through visual assessment one can detect changes in function. The learner will critique a SOAP note and defend or refute the documentation with differential diagnoses. Subjective Data The data gathered on the patient is lacking essential information that could be used in the diagnosis of the patient’s symptoms. It is crucial to obtain a thorough history of the patient, family, and specific abdominal complaints by detailing characteristics about them to generate proper diagnosis (Jarvis, 2011). The history of present illness should incorporate data like onset, duration, characteristics, exacerbating, and alleviating symptoms as it relates to abdominal pain. Location is one of the most critical questions to ask before the beginning exam (Ball,2015). To reframe from exacerbating pain more, the practitioner should avoid palpating the area until the very end. This allows for a thorough assessment. Simple differentiation of sharp verses dulls generalized pain could signal the organs associated with the symptoms experienced (Dains, 2016). It is also critical to determine the characteristic of the other symptoms related to a stomach ache. The gastrointestinal disease usually manifests in the presences of at least one or more of the following: change in appetite, weight loss, dysphagia, nausea and vomiting, changes and bowel habits (2011). In the subjective information provided the lack clarity in description of accompanying symptoms According to Ball, subjective assessment should include questions about diet including a 24hour history of meals, last bowel movement and characteristics thereof, recent travel history would also be useful information to note to account for suspected contracted GI disorders (Shaw, 2012). The family history of the patients seems to be completed; however, the patient’s personal history lacks detail. More information regarding his GI bleed would be a good place to start. Asking about whether it was an upper or lower GI bleed, diagnostics performed, results, medications used, complications, or the need for surgery and post-op care (2012). Comorbidities of the patient are also essential along with listed over the counter medications. Aspirins and the use of NSAIDs may cause abdominal pain and increase the likelihood of GI bleeds; therefore their application along with dietary supplements should be included within the report (Jarvis, 2011). Lifestyle risk factors are noted; however, the frequency and duration of alcohol consumpti.

1. Assessment of the Abdomen and Gastrointestinal System
Digestion, motility, and absorption are gastrointestinal system
processes that supply nutrients to all cells within the body.
Disruption within the GI could have effects that infiltrate other
systems causing side effects outside of the digestive tract. By
efficient and effective thorough documentation, the practitioner
can account for all symptoms related to illness to determine
possible disorder. By asking specific questions both
subjectively and through visual assessment one can detect
changes in function. The learner will critique a SOAP note and
defend or refute the documentation with differential diagnoses.
Subjective Data
The data gathered on the patient is lacking essential information
that could be used in the diagnosis of the patient’s symptoms. It
is crucial to obtain a thorough history of the patient, family, and
specific abdominal complaints by detailing characteristics about
them to generate proper diagnosis (Jarvis, 2011). The history of
present illness should incorporate data like onset, duration,
characteristics, exacerbating, and alleviating symptoms as it
relates to abdominal pain. Location is one of the most critical
questions to ask before the beginning exam (Ball,2015). To
reframe from exacerbating pain more, the practitioner should
avoid palpating the area until the very end. This allows for a
thorough assessment. Simple differentiation of sharp verses
dulls generalized pain could signal the organs associated with
the symptoms experienced (Dains, 2016). It is also critical to
determine the characteristic of the other symptoms related to a
stomach ache. The gastrointestinal disease usually manifests in
the presences of at least one or more of the following: change in
appetite, weight loss, dysphagia, nausea and vomiting, changes
and bowel habits (2011).
In the subjective information provided the lack clarity in
description of accompanying symptoms According to Ball,
subjective assessment should include questions about diet

2. including a 24hour history of meals, last bowel movement and
characteristics thereof, recent travel history would also be
useful information to note to account for suspected contracted
GI disorders (Shaw, 2012). The family history of the patients
seems to be completed; however, the patient’s personal history
lacks detail. More information regarding his GI bleed would be
a good place to start. Asking about whether it was an upper or
lower GI bleed, diagnostics performed, results, medications
used, complications, or the need for surgery and post-op care
(2012). Comorbidities of the patient are also essential along
with listed over the counter medications. Aspirins and the use of
NSAIDs may cause abdominal pain and increase the likelihood
of GI bleeds; therefore their application along with dietary
supplements should be included within the report (Jarvis, 2011).
Lifestyle risk factors are noted; however, the frequency and
duration of alcohol consumption should be included. Excessive
Alcohol consumption is a risk factor that could lead to liver
cirrhosis and esophageal varices (2012).
Objective Data
The objective assessment is the foundation of health care.
Engaging the in act of gathering information about the patient is
one of the first skilled taught a developed as it is the first step
of the nursing process ( Phillips et al., 2017) Upon examining
the objective information provided it would have been
advantageous to start with a general audit of the patient during
the assessment. Including elements of orientation, current
discomfort, brief psychosocial could give additional information
about the chief complaint (2017). Overall this follows the
guidelines of an expanded problem focused SOAP covering
affected organ systems (Sullivan, 2019). An affected organ
system not listed would be HEENT since the assessment of
these could preclude allergy issues, esophageal issues,
sensitives to smell, increased mucous since most of the immune
system is within the digestive tract. Overactive immune
response or changes in the gut bacteria can be triggered by
allergies (Gigante et al., 2011). Upon review of the vital signs

3. noted, increased temperature and blood pressures could imply
the patient discomfort during the visit. The integumentary
assessment could have been documented as only the exception
which would justify the documentation. Other information that
should be included if warranted for skin would be turgor,
capillary refill, and mucous membranes to assess for
dehydration (Ball, 2015).
The abdominal assessment is performed with inspection and a
combination of auscultation, percussion, and palpitation (Jarvis,
2011). From reading the objective note both auscultation and
palpitation are used. One could assume inspection as well.
Overall the note lacks the depth of the findings associated with
these three methods of assessment. Was there the presence of
any budges, masses, or hernias? Hyperactive bowel sounds
suggest that intestines are transporting foods and fluids at an
increased rate which would assist in the assessment process to
determine the probable cause of visit (Shaw, 2012). During
palpation, the practitioner assesses texture, tenderness,
temperature, moisture, pulsations, masses, lymph nodes, and
internal organs. Information documented should briefly address
the finding during this process (2012). The location of the
abdominal pain is noted. However, there is a classification of
abdominal pain. Is it Visceral, Parietal, or referred? According
to Dains, each of these classifications of abdominal pain are
specific and differ from each other in location, characteristic,
and onset (2016). Overall, the PQRST pneumonic could be used
to gather information that is possibly left out. Correctly, this
pneumonic assesses provocative, quality, region, severity, and
timing for symptoms related to the chief complaint.
Assessment Data
The lack of a Diagnostic test associated with the assessment is
also an error in assessment. With a patient history of a GI bleed
the labs that would be significant initially would be a complete
blood count. A primary metabolic panel could assess for
dehydration, liver dysfunction, cirrhosis, or hepatitis (Merck,
2018). Stool cultures may also be obtained to assess for signs of

4. infection, inflammation, or other digestive disease or disorders
(Caul, 1996). The Blumberg sign could also be initiated to test
for peritoneal irritation (Wholihan & Tilley, 2016). CT scans
and X-ray are used to assess for blockages.
The information from the assessment ruled that the patient was
suffering from left lower quadrant discomfort and
gastroenteritis. This assessment seems to be minimally
supported by both objective and subjective content. The patient
did report pain; however hyperactive bowel sounds were noted
on auscultation. Since most of the assessment lacked vital
information such as history, diagnostics, symptoms of illness,
differential diagnosis, diet, and comorbidities, supporting the
evaluation is futile. Viral gastroenteritis is an acute disease
accompanied by diarrhea, fever, abdominal pain, and nausea
(Bresee et al., 2012). Common characteristics of history
suggest an intermediate incubation period of 24 to 60 hours
with a short period of infection lasting no longer than two
weeks. Upon assessment, mild diffused abdominal tenderness is
noted, with voluntary guarding possible. Decrease skin turgor,
altered mental status, and dry mucous membranes would support
apparent dehydration (2012). Within the assessment portion, a
differential analysis is warranted to discuss decision more
thoroughly. There should be a union of subjective and objective
proof to lead to an assessed conclusion (Ball, 2015). With the
given information, the learner would move to support the
diagnosis as documented.
Differential Diagnosis
The three differential diagnosis
1. Bacterial Gastroenteritis
2. Diverticulitis
3. Gastritis or Ulcer
Evidence rejecting Bacterial Gastroenteritis is the symptom
profile associated with it. Patients diagnosed with this form of
gastroenteritis report high fever, serous bloody stools, anorexia
with nausea being the most common in emergency clinic

5. settings (Chan, 2003). The trademark side effect is its duration
which is for longer than 14 days. If this would be the diagnoses,
microscopic cultures that would indicate the presence of
Campylobacter, salmonella or enteropathogenic E. Coli. There
is no documented manifestation of either or test to support this
diagnosis.
Evidence rejecting gastritis is the lack of pathological factor. H.
Pylori is commonly observed with this diagnosis. Also, family
history of the patient doesn’t detail a history of gastritis or H
pylori disease which is associated with diagnosis ( Tsay & Hsu,
2018). The patient has no history of autoimmune disorders or
hypersensitivity that could cause gastritis. The patient does
have a vague alcohol assessment which could support the
diagnosis. Overuse of alcohol could destroy the mucosa of the
lumen exacerbating gastritis (2018). Side effects associated are
upper abdominal pain whereas our patient has lower abdominal
pain. Associated with ulcers the patient may develop dizziness,
black tarry stools, weakness, paleness, shortness of breath.
These side effects were not documented (2018). Diagnostics
would suggest testing for the pathological antigen, occult blood,
and complete blood count.
Evidence rejecting Diverticulitis is the lack of obstruction. The
patient did express left lower quadrate pain which made this
diagnosis worth considering since it occurs in the sigmoid
colon. Most common side effects associated however is
constipation, bloating, and nausea. Acute urinary issues are
possible as well. The assessment would suggest diminished
bowel sounds where the finding for the patient was hyperactive
with diarrhea (Lorenzo & Shifflette, 2017). The suspected
patient tends to have general guarding and tenderness upon
assessment laboratory finding would show leukocytosis which
could confirm the diagnosis. Phosphates, bilirubin amylase, and
lipase levels may be collected if perforation or diffused
peritonitis is apparent. The stool would be used to rule out
infectious etiologies (2017).
Conclusion

6. Finding alterations within the gastrointestinal assessment could
indicate likely issues that require sound knowledge and
understanding of assessment to determine correct diagnosing
and plan. Since assessment is the first step of the nursing
process, understanding all implications necessary for a full
focused noted for gastrointestinal findings allows for clear
insight into the plan and intervention. With a clear
understanding, the practitioner can intervene quickly and
appropriately to the identified disorder.
References
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