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Learning of the required components of documenting a problem based subjective and objective assessment of gastrointestinal system abnormal findings.

by | Nov 12, 2022 | Nursing

 

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1Module 04 Content
You will perform a history of an abdominal problem that your instructor has provided you or one that you have experienced and perform an assessment of the gastrointestinal system. You will document your subjective and objective findings, identify actual or potential risks in a narrative format and submit this in a Word document to the drop box provided.
Remember to be objective when you document; do not make judgments. For example, if the person has a palpably enlarged liver, do not write “the liver is enlarged probably because they drink too much.” Avoid stating that something is normal but instead state WHY you think it is normal. For example, if you think that the abdomen looks “normal” – which is subjective – then document that the “abdomen is flat, skin color consistent with rest of body, no lesions, scars, bulges, or pulsations noted.”
Title:Documentation of problem based assessment of the gastrointestinal system
Purpose of assignment:
Learning of the required components of documenting a problem based subjective and objective assessment of gastrointestinal system abnormal findings.
Course competency:
Priorities appropriate assessment techniques for gastrointestinal breast and genitourinary systems.
Instructions:
Content use of three sections subjective, objective,
Actual or potential risk factors for the client base on the assessment findings with description or reasons for selection of them
Format:
Standard American English correct grammar, punctuation etc.

 

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