750 words max. APA must be 100% accurate.

Objectives

• Demonstrate documentation of the abdominal assessment findings
• Explain how to conduct a physical assessment of the abdomen
• Develop a plan of care for the abdomen

Assignment Overview

In this writing assignment, you will review a case scenario and submit an assignment, providing information on how you would conduct a focused physical assessment of the client based on the presenting complaints. You will document your findings from the focused history and physical assessment data elicited and develop a nursing plan of care for this client.

The rubric used to grade this assignment is attached below the assignment description.

Deliverables

Write a 3-page (750 word) paper using APA 7.0 format style.

Step 1

Review the case scenario.

Gil Martin is a 55-year-old Hispanic male who presents to the clinic today with weakness, fatigue, and loss of appetite. He has a history of excessive alcohol use, chronic back pain, and hyperlipidemia.

• Onset: You ask Mr. Martin when he noticed his symptoms first began. He tells you he is not sure, but it seems like over the past year they have been getting worse. At first he thought it was just due to stress, but now he is not sure.
• Location: He tells you his weakness is “all over his body.”
• Duration: You ask Mr. Martin to describe how long his fatigue lasts. He tells you it is “pretty much all day.” He wakes up tired and never feels like he has any energy. You ask Mr. Martin to tell you about his appetite, when it changed, and has anything else occurred with the change. He tells you that in the last several months he has not really felt like eating much, and he often experiences nausea that just lingers throughout the day.
• Characteristics: You ask Mr. Martin to describe his weakness, and he tells you he isn’t sure if he is weak because he is tired, but he doesn’t seem to be able to do as much physical work as before. His back is always hurting though, so he thought maybe it was because of that. You ask Mr. Martin to describe his nausea; does it occur before eating or after eating? He tells you it occurs all the time. You ask him if his has any bloating or gas, and he tells you he doesn’t think so.
• Aggravating factors: You ask Mr. Martin if anything makes his nausea and loss of appetite worse. He tells you that when he drinks (alcohol), he never feels like eating anything. You ask Mr. Martin to describe anything that improves his fatigue, and he tells you that nothing does, even sleep doesn’t really help.
• Alleviating factors: You ask Mr. Martin if anything helps the nausea, and he tells you “not really.” You also ask him if anything improves his appetite, like eating his favorite foods. He tells you that he just never feels like eating. He only eats because his wife “nags” at him to eat. You ask him if anything helps his fatigue and weakness. He tells you “No, I am just tired all the time.”
• Other background information: Gil Martin is married with three children. He has two children with his current wife Helen (Anthony 21, Kristina 19). His 29-year-old son Mark (from a previous relationship) has been living at home since his spinal cord injury (MVA, DUI) two years ago. His mother also lives with them. His son Anthony has schizophrenia, has been non-compliant with his treatment, and creates frequent disturbances at home. Gil has had chronic back pain for years, which he often self-medicates with alcohol and prescription pain killers, when he can obtain them. He does not admit to being an alcoholic and has never sought treatment for his drinking, which he believes is normal considering his stressful home situation.

You perform the following assessment:

• Abdominal: Abdomen is protuberant, bowel sounds are active in all four quadrants, dullness during percussion of the liver suggests liver enlargement. Dullness is noted also during percussion of the abdomen suggesting ascites. Palpation of the liver also suggests enlargement but no nodules felt. No rebound tenderness noted. Percussion of the spleen is normal.

Diagnosis and treatment: Mr. Martin is sent for an abdominal CT scan and blood work is done to measure his liver function. He is diagnosed with cirrhosis of the liver and is told he needs to stop drinking.

Step 2

Write a 3-page (750 word) paper using APA 7.0 format style and address the information below. As a minimum, the resources for this assignment should by the required course textbook and any article you are asked to read. The next level of evidence you may use would be peer reviewed articles after that well known web sites for example CDC or the AHA. Avoid blogs or obscure web sites. Never cite/reference Wikipedia.

You are precepting a student nurse today who is taking her assessment class. She is learning about focused history and assessment skills. In your paper, discuss the following items:

• Write a detailed explanation describing what you would say to the student when explaining the assessment conducted and the findings. Discuss any additional assessments you would also perform. What are other potential factors related to the probable diagnosis you would be concerned about with this client?
• Explain how you would document your findings in the medical record.
• Develop your plan of care. Identify two nursing diagnoses and two nursing interventions related to those diagnoses. The interventions should be evidence based. Cite the references used in your plan in APA7.0 formatting.
• Identify specific client education should be done for Mr. Martin, given his background and presenting concerns. Describe your teaching strategy and how you will evaluate the effectiveness of the educational intervention.
• Be sure to cite all the sources you used in the completion of this assignment and include a reference list.

*Link to course textbook below:

Cover

Lapum, J. L. & Hughes, M. (2024). Introduction to health assessment for the nursing professional (2024)- Canadian edition. Creative Commons Attribution-NonCommercial 4.0 International License.