Sample abdominal assessment documentation evaluation procedure

Making sense of abdominal assessment With abdominal assessment, you inspect first, then auscultate, percuss, and palpate. Throughout the course, you will learn that deviations in your assessment findings could indicate potential gastrointestinal problems. The head-to-toe assessment includes all the body systems, and the findings will inform the health care professional on the patient's overall.

Figure Ileostomy bag Figure Abdominal distension: Abdominal distension may indicate ascites associated with conditions such as heart failure, cirrhosis, cancer. Ascites - An abnormal accumulation of serous fluid in the abdominal cavity containing large amounts of protein and electrolytes. To conduct a thorough assessment, the SSW must take into consideration information received from all alleged victims, alleged perpetrators, non-offending caretakers. The 1997 version of Medicare's "Documentation Guidelines for Evaluation and Management Services" defines complete exams for 11 organ systems and significantly expands the definitions for multi.

It is a very common and nonspecific complaint that can be difficult to diagnose, especially for the family nurse practitioner student. The difference is based on the fact that physical handling of peritoneal contents may alter the frequency of bowel sounds. A comprehensive head-to-toe assessment is done on patient admission, at the beginning of each shift, and when it is determined to be necessary by the patient's hemodynamic status and the context. The abdominal examination is always a step-wise procedure, and the experienced practitioner should follow the same sequence for all patients, using age-specific modifications to achieve the desired goals. A history and physical examination, focusing on risk factors for cardiac, pulmonary and infectious complications, and a determination of a patient's functional capacity, are essential to any.



This order is different from the rest of the body systems, for which you inspect, then percuss, palpate, and auscultate. Documentation of a basic, normal abdominal exam should look something along the lines of the following: Abdomen is soft, symmetric, and non-tender without distention. Abstract: This article serves to assist the novice family nurse practitioner student in the examination of abdomen in a patient presenting with acute abdominal pain.


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