Assignment:
A 19-year-old woman attending the local university experiences increasing urinary frequency, along with urgency and dysuria for 3 days. Over the next 12 hours or so, these symptoms persist, and her urine is pinkish. She then becomes concerned and goes to the campus student health clinic for advice. You are the nurse at the campus health clinic. Vital signs are: T = 37.5ºC, P = 105, R = 18, and BP = 105/70 mm Hg. The only abnormal finding on physical examination is....
The assignment reads to do a GI assessment, and the case study I have provided you has GU symptoms. So, I'm asking you to do a full ABDOMINAL assessment on this client. Practice the subjective questions you would ask AND the objective data you would need to collect for both gastrointestinal and genitourinary systems. This would be a realistic situation presenting to the ED or Urgent Care and if you omit the assessment on one of those systems, the provider may miss the diagnosis. How do you know which one is causing the problem unless you check them all out?
Title:
Documentation of problem based assessment of the gastrointestinal system.
Purpose of Assignment:
Learning the required components of documenting a problem based subjective and objective assessment of gastrointestinal system. Identify abnormal findings.
Course Competency:
Prioritize appropriate assessment techniques for the gastrointestinal, breasts, and genitourinary systems.
Instructions:
Content: Use of three sections:
o Subjective
o Objective
o Actual or potential risk factors for the client based on the assessment findingswith description or reason for selection of them.
Format:
• Standard American English (correct grammar, punctuation, etc.)
Resources:
Chapter: SOAP Notes: The subjective and objective portion only
Sullivan, D. D. (2012). Guide to clinical documentation. [E-Book].
Smith, L. S. (2001, September). Documentation do's and don'ts. Nursing, 31(9), 30.