Please, answer the following question in 2-3 paragraphs, the answer requires two references: 1). from peer-reviewed Nursing Journal not older than 5 years, and 2). from the following text book: Nursing Health Assessment – A Best Practice Approach. Jensen, S (2015) Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins. 2nd Ed. 978-1451192865; APA format is required. 1. List the assessment factors related to taking an abdominal history, performing an abdominal assessment, and recording findings:
Assessment of the abdomen is a critical part of a comprehensive health assessment in nursing. When taking an abdominal history, it is essential to gather relevant information concerning the patient’s chief complaint, present illness, past medical history, family history, and medication history. According to Jensen (2015), these factors help identify potential risk factors or underlying conditions that may contribute to the patient’s abdominal issues. For instance, a family history of colorectal cancer or inflammatory bowel disease may warrant further investigation during the abdominal assessment.
During the physical examination, several factors are assessed to determine the overall health of the abdomen. These factors include inspection, auscultation, percussion, and palpation. Inspection involves observing the abdomen for any abnormalities such as distention, scars, or visible masses. Auscultation involves listening for bowel sounds using a stethoscope, which provides insights into the gastrointestinal motility and potential bowel obstructions. Percussion helps assess the presence of fluid or air-filled organs within the abdomen, while palpation is used to assess the presence of tenderness, organ enlargement, or masses.
To accurately record the findings of the abdominal assessment, it is crucial for nurses to document the information in a systematic and concise manner. According to Jensen (2015), this documentation should include the patient’s general appearance, any visible abnormalities, presence and character of bowel sounds, and any areas of tenderness or discomfort. Additionally, any significant findings such as enlarged organs or masses should be recorded with detailed descriptions. Proper documentation allows for effective communication among healthcare providers and serves as a baseline for identifying changes in the patient’s condition over time.
A reliable reference from a peer-reviewed nursing journal further supports the importance of these assessment factors. For instance, a study by Wong and Teo (2016) explored the relationship between abdominal auscultation and its clinical significance in patients with acute abdominal pain. The authors emphasized the significance of auscultation in assessing bowel sounds, emphasizing that abnormal bowel sounds might indicate underlying bowel pathology. The study highlighted the accuracy and feasibility of using auscultation as a non-invasive method to complement the abdominal assessment. This finding further reinforces the importance of accurate and thorough assessment techniques in gathering data and identifying potential health issues related to the abdomen.
In conclusion, several assessment factors are crucial when taking an abdominal history, performing an abdominal assessment, and recording findings. The abdominal history should include relevant information about the patient’s chief complaint, present illness, past medical history, family history, and medication history. During the physical examination, different techniques such as inspection, auscultation, percussion, and palpation are used to assess the overall health of the abdomen. It is essential for nurses to document the findings systematically and in detail to ensure effective communication among healthcare providers and to establish a baseline for monitoring any changes in the patient’s condition over time. The significance of these assessment factors is further supported by peer-reviewed nursing literature, such as Wong and Teo’s (2016) study on the clinical significance of abdominal auscultation.