Health assessment is an evaluation of the health status of an individual by performing a physical examination after obtaining a health history. (Mosby’s Medical Dictionary, 2009) At the followings, I choose abdomen case in health assessment to apply on a client I had been caring in my past clinical practice. To diagnose, monitor, and treat client’s conditions, abdominal assessment skills are essential and it can be anticipate a different outcome of care to this client.
Case
Here is the case that I choose in my past clinical practice. Mr. Lee, a 26-year-old male, complains of severe abdominal cramping, nausea, vomiting and diarrhea since yesterday. States that he ate dinner yesterday at Eastern and Western restaurant and 5-6 hours later noted cramping, diarrhea and vomiting. Has had a watery, brownish stool about every hour since yesterday. No loner vomiting or crampy.
Vital signs
When Mr. Lee sent to our ward, I began the physical examination by taking his vital signs. Vital signs provide data that reflect the status of several body systems.
After taking his vital signs, I started to ask him some health history, his lifestyle & health practices. Health history is an excellent way to begin the assessment process because it lays the groundwork for identifying nursing problems and provide a focus for the physical examination. (Weber & Kelley, 2010)
Health history
The health history that I asked are included present health, past health history, family history, lifestyle and health practices. In present health I asked some questions such as “Are you experiencing abdominal pain?”“How did the pain begin”“Where is the pain located?”Those questions are want to ascertain the chief complaint. Then I asked something about nutrition, appetite, nausea and vomiting, recent change in eating pattern or foods, recent weight loss or gain. Allergies on food or medications.
Past health history that I asked are his previous gastrointestinal problems, such as peptic ulcer, intestinal obstruction or gallbladder disease. History of major illnesses, such as cancer (type), arthritis (specify steroid or aspirin use), kidney disease, cardiac disease, respiratory disease(steroid use), any blood transfusions, DM, hypertension, needle exposure and hepatitis vaccination status.
After taking past health history, I asked him something about family health history. “Is there a history of any of the following diseases or disorders in your family: colon, stomach, pancreatic, liver, kidney or bladder cancer; liver disease?”
And the last one that I asked in health history is lifestyle & health practices. Asked him about activities of daily living, his abilities for self-care, also asked his psychosocial history, such as cigarette smoking status (number of packs/day and number of years of habit) , alcohol intake(usual amounts and frequency), recent stressful life events.( Mcgough, 2003)
After checking Mr. Lee vital signs and his health history, I started to summaries some data that I collected, Mr. Lee had a watery, brownish stool about every hour since yesterday. No longer vomiting or crampy. Denies blood or mucus in stools. States is usually healthy. No chronic illnesses. Denies history of constipation, indigestion, weight changes, or change in appetite. Has not taken any medications. No family history of liver, peptic ulcer, or kidney disease. Smokes one packs/day x 8 years; non-drinker. Denies increased stress or major life changes; states family situation is good; lives with parents and his brother. His vital signs: Bp 116/72, pulse73, respiration18, temperature 37.7°C.
When I finished ask Mr. Lee’s health history and check his vital signs. I found that I am more understood Mr. Lee’s situation so that I can provide some appropriate care for him. However I think I am not doing enough health assessment on this case. To care this case again, I think I will ask Mr. Lee’s health history and check his vital signs, also try to have physical examination on Mr. Lee.
Physical examination
Physical examination of the abdomen includes all four methods of examination (inspection, auscultation, percussion and palpation). In the abdominal examination, auscultation is done before percussion and palpation because stimulation by pressure on the bowel cal alter bowel motility and heighten bowel sounds. ( Barkauskas, Baumann & Darling-Fisher, 2002)
First I will help Mr. Lee to relax. It is an important prerequisite to performing a thorough examination of the abdomen. Mr. Lee should have an empty bladder before the examination begins. He needs to be in a comfortable supine position with arms at the sides. To help him to relax the stomach muscles, place a small pillow under the head and ask the client to flex the knees slightly. The examination room should be warm enough so that the client will not shiver. The abdomen must be fully exposed. ( Barkauskas, Baumann & Darling-Fisher, 2002)
Moreover I need to prepare some equipment. Stethoscope(with bell and diaphragm) to listen to bowel and vascular sounds, Centimeter ruler to measure liver span, Marking pen to mark borders of organs, small pillows to position client.
To describe clearly the location of organs and the areas of pain or tenderness, the abdomen can be divided into four quadrants. An imaginary vertical line is drawn from the sternum down to the pubic bone through the umbilicus, and a second line is drawn perpendicular to the first line through the umbilicus. Start the assessment in the RLQ, proceeding in a clockwise direction. Different abdominal quadrant is stand for different organs, such as right upper quadrant stand for duodenum, gallbladder ( Barkauskas, Baumann & Darling-Fisher, 2002).
Inspection
First for inspection, it means systemic and thorough visual examination of the abdomen. Observe the coloration of the skin. Abdominal skin maybe paler than the general skin tone because this skin is so seldom exposed to the natural elements. Moles and striae (silvery-white lines caused by rapid stretching of the skin) are common findings. A network of fine veins may be seen around the umbilicus and abdomen and gently pinch and release a fold of skin to assess turgor( the skin should return quickly to normal) (Weber & Kelley, 2010).
The observation of skin lesions or nodules is of particular significance because gastrointestinal alterations are frequently associated with skin changes. Inspection of the abdomen for scars may yield valuable data concerning previous surgery or trauma. The size and shape of scars are best described through the use of a drawing of the abdomen on which the landmarks or quadrants are shown the dimensions are noted in centimeters ( Barkauskas, Baumann & Darling-Fisher, 2002).
To inspect Mr. Lee’s abdominal contour. Look across the abdomen at eye level from the client’s side, from behind the client’s head, and from the foot of the bed. Measure abdominal girth as indicated. In normal findings abdomen is flat, rounded or scaphoid. Abdomen should be evenly rounded. (Weber & Kelley, 2010)
Assess abdominal symmetry. Look at the Mr. Lee’s abdomen as he lies in a relaxed supine position. Abdomen is symmetric in normal finding. Inspect abdominal movement when the client breathes. Abdominal respiratory movement may be seen, especially in male clients because men exhibit predominantly abdominal movement with respiration.
Observe aortic pulsations and peristaltic waves. The normal findings are that a slight pulsation
of the abdominal aorta, which is visible in the epigastrium, extends full length in thin people. Normally peristaltic waves are not seen although they may be visible in very thin people ( Barkauskas, Baumann & Darling-Fisher, 2002).
Auscultation
Secondly, auscultation follows inspection and provides valuable information about gastrointestinal motility and underlying abdominal vessels and organs. (Cox C & Stegall M, 2009) Start auscultation, both the stethoscope and the nurse hands should be warm. If they are cold, they may initiate a contraction of the abdominal muscles. To listen to the relatively high-pitched abdominal intestinal sounds, use the diaphragm of the stethoscope, which accentuates the higher-pitched sounds. Use the bell of the stethoscope to listen for low-pitched arterial bruits and venous hums. ( Barkauskas, Baumann & Darling-Fisher, 2002)
Peristaltic sounds. Normal bowel sounds are high-pitched, gurgling noises that occur approximately every 5 to 15 to 20 seconds or roughly one bowel sound for each breath sound. The frequency of sounds is related to the presence of food in the gastrointestinal tract or to the state of digestion. A silent abdomen indicates the arrest of intestinal motility. Flick the abdominal wall with a finger to stimulate peristalsis. Peristaltic sounds maybe quite irregular,
so it is essential to listen for at least 15 minutes before concluding the absence of bowel sounds. ( Barkauskas, Baumann & Darling-Fisher, 2002)
Auscultate for vascular sounds. Use the bell of the stethoscope to listen for bruits (low-pitched, murmurlike sound) over the abdominal aorta and renal, iliac, and femoral arteries. Furthermore, auscultate for a friction rub over the liver and spleen. Listen over the right and left lower rib cage with the diaphragm of the stethoscope. No friction rub over liver or spleen is present in normal finding. (Weber & Kelley, 2010)
Percussion
In addition, abdominal percussion aids in determining the size and location of abdominal organs. Percussion also aids in the assessment of excessive accumulation of fluid or air in the abdomen. As in auscultation, a systematic approach should be used in percussing all four quadrants. Percussion
sounds vary depending on the density of the organ and the underlying structures. Dull sounds are heard over dense structures, like the liver and spleen, and tympanic sounds are heard over air filled structures (Cox C & Stegall M, 2009).
To determine the size of the liver, begin percussion in the right midclavicular line at a level below the umbilicus. Start percussion over a region of gas-filled bowel and progress upward toward the liver. The first dull percussion note indicates the lower border of the liver. Mark the lower border on the abdomen. The usual liver span is 6 to 12 cm in the midclavicular line and 4 to 8 cm in the midsternal line( Barkauskas, Baumann & Darling-Fisher, 2002).
Percussion for tympany and dullness. Percussthe spleen. Begin posterior to the left mid-axillary line (MAL)., and percuss downward, noting the change from lung resonance to splenic dullness. (Weber & Kelley, 2010).
Morever, percussion note of the gastric air bubble is lower-pitched tympany than that of the intestine. Another percussion method used in the abdominal examination is fist percussion, which causes the tissue to vibrate rather than produce sound.
Palpation
Palpation is the final component in an abdominal assessment and is used to assess the organs of the abdominal cavity, to detect muscle spasm, tumours, fluid and areas of tenderness. It is a sophisticated skill that involves the use of the hands and fingers to gather information about
the size, shape, mobility, consistency and tension of abdominal contents through the sense of touch. Touch is considered therapeutic, and is the actuality of ‘laying on of hands’. Palpation of the abdomen is a particularly sensitive matter; therefore, the nurse’s approach should be gentle. (Cox C & Stegall M, 2009)
Different outcome of care
This selected assessment might anticipate a different outcome of care Mr. Lee, it is because it can let me know more information about him and it can find a source of his diseases.
After performing an inspection examination on Mr. Lee, he is flat no visible masses, pulsations or peristalsis. Also he has hyperactive bowel sounds in all four quadrants in auscultation. Tympany in all four quadrants on percussion. He has tenderness over epigastric area; slight tenderness in all four quadrants; no masses or organomegaly; negative Murphy and Mcburney’s sign.
Finally all health assessment is done; I found that he was suffering from acute gastroenteritis in rule out food poisoning. Sometimes the signs of symptoms in acute gastroenteritis are
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nausea, vomiting, diarrhea, malnutrition and fever (Mingpao, 2011).Compare with physical assessment, if only check Mr. Lee’s history and vital signs, the care that I provide surely is not enough, so that a complete health assessment can help me to find appropriate method to care Mr. Lee and make a professional clinical judgment.
After taking all health assessment, I know how to care Mr. Lee. I will maintain adequate fluid intake with appropriate rehydrating solutions. Never rehydrate with water alone because it does not contain adequate amounts of sodium, potassium, and other important nutrients. Take stool sample and blood for culture. Give ice pad when Mr. Lee has fever. (Hong Kong Hospital Authority, 2007)
ConclusionAll in all, a complete and well health assessment aids in determining the correct diagnosis and devising the treatment plan, it is useful to use in clinical field and it might anticipate a different outcome of care to client after all health assessment is done.
ReferencesBarkauskas, V.H., Baumann, L.C. & Darling-Fisher, C.S. (2002). Health physical assessment (3rd ed.).Arizona: Mosby.
Cox, C., & Stegall, M.(2009). A step-by-step guide to performing
a complete abdominal examination. Gastrointestinal Nursing, 7 (1),10-17.
Hospital Authority.(2007). Gastroenteritis?Brochure?.Hong Kong:Hong Kong Government press.
Mcgough, K. (2003). Home health nursing assessment and care planning.(4th ed.).Arizona: Mosby.
Mosby’s Medical Dictionary .(2009). Health Assessment. From http://medical-dictionary.thefreedictionary.com/health+assessment.
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