36 hours ago Abdominal Pain SOAP Note Medical Transcription Sample Report. SUBJECTIVE: The patient continues to have significant abdominal pain as well as back pain. She states that the pain is about a 7/10 currently and is located just below and lateral to her umbilicus and the previous scar site. She complains of lumbar burning back pain as well. >> Go To The Portal
For epigastric abdominal pain related to infection, a doctor will prescribe antibiotics if bacteria are the cause. Surgery or endoscopic procedures may be necessary for some causes of epigastric pain, such as hiatal hernia, esophagitis, gallbladder disease, and gastric ulcer. Most cases of epigastric pain are related to the digestive system.
This lesson will look at how a nurse can write a care plan for abdominal pain no matter the underlying diagnosis. Understand and explain the nursing interventions and rationales associated with an abdominal pain nursing care plan
To diagnose your condition, your doctor or licensed healthcare provider will ask you several questions related to your epigastric pain including: Where precisely do you feel the pain? How long have you felt epigastric pain? Are there certain times your epigastric pain is more severe? Are you lactose intolerant?
The emergency physician should not hesitate to administer adequate analgesic medication to the patient with acute abdominal pain. When studied, the administration of narcotic analgesics does not obscure the diagnosis or interfere with the treatment of the patient.
Abdominal assessment may reveal a mass in the right lower quadrant that is tender to palpation, or signs of peritoneal irritation such as rebound, involuntary guarding and abdominal wall muscle spasms. Any movement of the patient (e.g., bumping the stretcher) may elicit severe pain.
The American College of Radiology has recommended different imaging studies for assessing abdominal pain based on pain location. Ultrasonography is recommended to assess right upper quadrant pain, and computed tomography is recommended for right and left lower quadrant pain.
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. There are no visible lesions or scars. The aorta is midline without bruit or visible pulsation.
5 Questions to Ask If You Have Stomach PainSeverity: Is the pain so severe that when it's present, you can't focus on or do other things?Vomiting: Are you also vomiting? ... Output: Okay, no one likes to talk about this, but I'm a doctor, so I have to ask. ... Other symptoms: Are you having difficulty breathing?More items...
Simultaneous amylase and lipase measurements are recommended in patients with epigastric pain. Ultrasonography is the imaging study of choice for evaluating patients with acute right upper quadrant abdominal pain.
Abdominal Pain Nursing Care Plan 1 Nursing Diagnosis: Acute Abdominal Pain related to stomach spasms, secondary to irritable bowel syndrome (IBS), as evidenced by abdominal pain, high pain score rating, verbalization of pain or discomfort in the abdominal region, abdominal guarding, and cramping.
Place the palmar aspect of the fingers on your dominant hand flat and together on your patient's abdomen. Using a light, gentle, dipping motion, palpate for abnormalities, such as muscle guarding, rigidity, or superficial masses. Palpate clockwise, lifting your fingers as you move from one location to another.
The inspection of the abdomen includes looking for scars, striae, venous pattern, rashes, contour, symmetry, masses, peristalsis, and pulsations. Inspection is optimum with the patient lying flat on the examination table, breathing normally. As this is being done, note the comfort level of the patient.
The major components of the abdominal exam include: observation, auscultation, percussion, and palpation.
Abdominal painDoes the patient use a single finger or spread the fingers and move the palm over much of the abdomen?What is the nature of the pain? Note body language. ... Are there any aggravating or relieving factors? ... How often is the pain felt and how long does it last?Is there radiation elsewhere?
If the patient is experiencing abdominal pain, the nurse should ascertain its location, duration, intensity, factors that make it worse, and factors that make it better.
Assist the patient to lie down in a position of greatest comfort, usually on the back or on the uninjured side, with both knees drawn up for relief of pain and spasm.
For epigastric pain due to such common conditions as indigestion and acid reflux: Avoid carbonated drinks as well as coffee and alcohol. Avoid spicy, greasy and acidic foods. Drink water with baking soda (1 teaspoon for 8 ounces of water).
Along with an exam of your heart and lungs, the doctor will also look at and feel your abdomen for possible abnormalities, bruising, masses, painful areas, and gas or fluid.
Epigastric pain may have other causes including: Barrett’s esophagus (cellular changes in the esophagus that may lead to esophageal cancer) Pancreatitis (inflammation of the pancreas), where epigastric pain may radiate to the back.
Epigastric pain can be caused by digestive conditions, such as acid reflux or lactose intolerance.
Epigastric pain is upper abdominal pain right below the ribs. “Epi” means “over” or “upon” and “gastric” means “of the stomach,” although the epigastrium also houses the pancreas and parts of the liver and small intestine. Oftentimes, those who experience this type of pain feel it during or right after eating or if they lie down too soon ...
Other symptoms that may accompany epigastric pain include abdominal bloating, constipation, diarrhea, and vomiting, depending on the underlying cause. In rare cases, epigastric pain is due to heart conditions such as heart attack and angina (chest pain due to the heart not getting enough oxygen).
In some cases, symptoms of epigastric pain can be a sign of a heart attack or serious condition . Seek immediate medical care (call 911) if you or someone you are with are experiencing any of these life-threatening symptoms, including: Chest pain, chest tightness, chest pressure, palpitations.
Abdominal pain can be due to issues with the GI tract. It is essential to proactively address nausea, vomiting, constipation, and diarrhea as clinically appropriate. Patients with abdominal pain may not be taking in the necessary amount of fluids or foods. Their urinary and/or bowel output may also be lacking.
It is essential to report bowel movement characteristics and frequency accurately. It also ensures accurate intake and output recording. Ensure adequate hydration; may require intravenous fluids. Patients with abdominal pain may have a diminished appetite, be NPO, or not want to drink fluids.
Abdominal pain can be a minor issue that is easy to resolve or a medical emergency. Many different things can cause abdominal pain and their pathophysiology can differ widely. Abdominal pain can is classified as either acute or chronic.
Just in general, for any abdominal pain patient, you have to find what the cause is, because then you can fix that, and then it will fix the pain. This could vary. We could address it with, if it’s constipation causing abdominal pain, then a laxative, if we have electrolyte balances, we’re going to fix that.
Additionally, abdominal pain can be referred pain, which can complicate the clinical picture even further.
Pain may spread from or to another part of your body. Epigastric pain may be a sign of a serious health problem that needs to be treated.
Certain foods may cause your pain, such as alcohol or foods that are high in fat. You may need to eat smaller meals and to eat more often than usual. Drink liquids as directed. Ask how much liquid to drink each day and which liquids are best for you. Do not have drinks that contain alcohol or caffeine.
Signs and symptoms will depend on what is causing your pain. Nausea, vomiting, bloating, constipation, or diarrhea. Loss of appetite, weight loss, feeling of fullness as you start to eat. Movement relieves the pain or makes it worse, or only certain positions are comfortable.
Also include any foods you ate or activities you did before the pain started. Keep track of anything that helped the pain. Eat a variety of healthy foods.
Hindgut structures such as the bladder, and distal two-thirds of the colon, as well as pelvic genitourinary organs usually cause pain in the suprapubic region. Pain is usually reported in the back for retroperitoneal structures such as the aorta and kidneys.5,6. Character .
Although labeled “colic,” gallbladder pain is generally not paroxysmal, and it almost never lasts less than 1 hour, with an average of 5–16 hours’ duration, and ranging up to 24 hours.13Small bowel obstruction typically progresses from an intermittent (“colicky”) pain to more constant pain when distention occurs.
Somatic pain is transmitted via the spinal nerves from the parietal peritoneum or mesodermal structures of the abdominal wall. Noxious stimuli to the parietal peritoneum may be inflammatory or chemical in nature (eg, blood, infected peritoneal fluid, and gastric contents).5,7. Onset .
Location . Embryology determines where a patient will “feel” visceral pain, which is generally perceived in the midline because afferent impulses from visceral organs are poorly localized. Visceral nociceptors can be stimulated by distention, stretch, vigorous contraction, and ischemia.
The emergency physician should not hesitate to administer adequate analgesic medication to the patient with acute abdominal pain. When studied, the administration of narcotic analgesics does not obscure the diagnosis or interfere with the treatment of the patient.
Vomiting may occur in almost any abdominal disease. Pain generally precedes vomiting in surgical conditions, with the important exception of esophageal rupture from forceful emesis.10,17It is usually present in small bowel obstruction, unless the obstruction is partial or the patient is presenting early in the course.