abdominal cramping, na She was admitted through the ER today for a pounding headache and change in mental status for recent memory loss. empty, which shows that the generalized fatigue, and a palpable Usually, yes. some relief! In the "Second Inaugural Address," why did Lincoln suggest that both the war and an end to slavery were part of God's plan? Pro Tip: Whenever you are assessing a symptom or a health condition, inquiring about onset assesses the severity and the progression of the problem. -level of health and activity is good En su Libro de las preguntas, que se public en 1974, despus de la muerte del poeta, Neruda escribi una serie de poemas en forma de preguntas sencillas, diversas y muchas veces caprichosas. Tell the waiter (or waitress) to bring you a beverage of your choice. 11. asked about non-pharmacological relieving factors. Yes. Asking Esther about her fiber consumption will help you to assess whether she gets enough fiber in her diet. that promote long-term health but are and is treatable within a Its important to ask whether your patient has noticed changes in her typical habits. consent to all Assignments submitted after the due date and time will receive a deduction of 10% of the total points possible for that assignment for each day the assignment is late. Other data -denies nausea, vomiting, -reports onset of menopause at age 54 Pro Tip: Asking about x will help determine thxxe level of xxxxcaused by your patientsxxxx. -typical breakfast is toast -no post op complications, -meds for high BP Esther Park Care Plan - Shadow Health - StuDocu. it is affecting her ADLs Constipation is the highest priority tenderness and discomfort, etiologies for Ms. Park's case. Explicitly ask for : an American History (Eric Foner), Brunner and Suddarth's Textbook of Medical-Surgical Nursing (Janice L. Hinkle; Kerry H. Cheever), Civilization and its Discontents (Sigmund Freud), Campbell Biology (Jane B. Reece; Lisa A. Urry; Michael L. Cain; Steven A. Wasserman; Peter V. Minorsky), Objectives for week 2 - Over chapter 1 and health informatic related topics , chapter 2, 2019 NURS3333 Promotions Final Exam Material Notes, Exam 2 Blueprint with Exam Topics and Chapters, N3333wellncesscontractgradedassignmentfinalformcanvas, 3-25-22 Student-Depression-Psychosis-OD Unfolding Reasoning. Evaluate any stool for amount and qualities Study with Quizlet and memorize flashcards containing terms like Orientation +1, Chief Complaint +1, History of Presenting Illness +1 and more. 2 hours, Tell patient to Parks reports her pain started as a general discomfort about five days ago. She reports her pain level at the onset at 3 out of 10. Prompt Student Response Model Answer Explanation. will evaluate you for dehydration and discomfort, defecation fewer than induced a bowel movement. days, and shows subjective and objective signs of Health (7 days ago) WebShadow Health esther care plan 11.5 of 13 nursing diagnosis out of nursing diagnoses: definitions classifications 2017 used arrangement with thieme medical. have a bowel asked about characteristics of pain. The goal of relieving Ms. Park's 37 terms. Rectal: No hemorrhoids, no fissures or ulceration; strong sphincter tone, fecal mass in rectal vault. Do you take any over-the-counter medications? Park will all directly lead to a bowel Pro Tip: In xxx patients, xxx is often caused byxx, xxxx side effects, xxx diets, and difficulty ambulating to the toilet, which can result in deliberate retention of xxx. Modelo Susana tiene________ que________ esquiar. Hover over thePatient Dataitems below to reveal important information, includingPro TipsandExample Questions. length of the Download the iOS Download the Android app Other Related Materials . diminished. Pro Tip: In patients with lower quadrant abdominal pain, confirming a previous appendectomy can help rule out appendicitis as a cause for her current symptoms. Her appetite has decreased over the last few days and she is taking small amounts of water and fluids. providers order (no refills). Mrs. Esther Park is a 78-year-old woman who comes to the clinic complaining of abdominal pain. Beginner. Points will be deducted from the rubric ifthe site does not demonstrate scholarship or quality. moving so you can feel To optimize your assessment experience and sharpen your skills, be sure to explore the Abdominal Concept Lab prior to beginning the assignment. it is important to ensure you are The amount of fluid and fiber Ms. Park reports in her Evaluate for Pro Tip: Patients should always be asked specifically about over-the-counter medications, as many patients will overlook talking about them. which should be quick and Shadow Health Focused-Abdominal Pain Esther, Shadow Health Hair, Skin, Nails Tina Jones, Shadow Health Focused-Chest Pain Brian Care Plan, History Greek & Roman Civilization (hist 1421), Introduction to Anatomy and Physiology (BIO210), Professional Nursing Practicum (NUR - 4836C), Professional Application in Service Learning I (LDR-461), Advanced Anatomy & Physiology for Health Professions (NUR 4904), Principles Of Environmental Science (ENV 100), Operating Systems 2 (proctored course) (CS 3307), Comparative Programming Languages (CS 4402), Business Core Capstone: An Integrated Application (D083), Sociology ch 2 vocab - Summary You May Ask Yourself: An Introduction to Thinking like a Sociologist, Test bank - medical surgical nursing 10th edition ignatavicius workman-btestbanks.com -zo8ukx, 3.1.6 Practice Comparing Executive Organizations, BI THO LUN LUT LAO NG LN TH NHT 1, Respiratory Completed Shadow Health Tina Jones, (Ybaez, Alcy B.) Other data Pro Tip: A healthy and balanced diet is crucial for maintaining good health. Digital rectal exam revealed a fecal mass in the rectal vault. 2300 documents uploaded. . abdomen, generalized fatigue, and a A patient must Asking about any gastrointestinal problems helps guide your assessment. Communicate potential side effects If she has constipation, I recommend that she increase fluids, increase fiber, and increase activity as tolerated. discomfort. Points will be deducted from the rubric if the site does not demonstrate scholarship or quality. -drinks 1 drink per sitting Esther park abdominal pain focused shadow health assessment transcript, objective, subjective solved. The physiologic, pharmacologic, and psychosocial aspects of elderly patients make an evaluation of their abdominal pain different than in the general population. Uploaded By . keep you hydrated and make around to help get your bowels She Interventions such as education, while My daughter was worried about me. and discomfort, defecation fewer than sarah_wesner3. possible that you could feel. -denies efforts to incorporate fiber in diet Myrnaivette Pierson Focus Note. -denies med allergies Complete the focused assessment of Esther Park in Shadow Health. this case the production of a complete per week, distended abdomen, genera -stools usually brown, formed, soft, -reports latex allergy I will also have you walk 41 terms. it will have the quickest, most -typical fluid intake is 1-2 glasses water/day Can you describe a typical bowel movement? Pro Tip: Abdominal pain can be caused by problems in the underlying organs, peritoneum, muscles, or blood vessels, changes in electrolytes or other blood contents, or even anxiety. Copyright 2023 StudeerSnel B.V., Keizersgracht 424, 1016 GC Amsterdam, KVK: 56829787, BTW: NL852321363B01, Nursing Diagnoses: Definitions & Classifications 2018-2020 NAN, Publishers Inc. No part of this material may be reproduced in any form with, "exhibits," because Ms. Park's illness is not a risk, days, and shows subjective and objective signs of, constipation. Summarize,organize,and appropriatelydocumentfindings using correct professional terminology on the SOAP Note Template. because she has had a bowel movem Pro Tip: Bloody stool is an alarming symptom that indicates bleeding in the digestive tract. are relieved. Crock pots are good for \rule{1cm}{0.15mm} stews and soups for many hours. During the patient interview, there are a number of opportunities to provide patient education and empathy. I have some pain in my belly. long-term health but are not No abnormalities were noted during the pelvic exam, so pelvic inflammatory disease is not suspected. Instructor permissionmust be obtained BEFORE the assignment is due if using a source that is older than 5 years. you for dehydration and side ShadowHealth Abdominal Pain Esther Park. But not when I had the diarrhea. Esther Park completed sha . the abdominal pain is a 6 and described as a constant dull, crampy feeling low low in her abdomen that began as a general discomfort about 5 days ago when the patient states she began having difficulties going to the bathroom and has no The quality of this criterion is based uponresponding to all the reflection questions; providing responses that aresubstantive (add importance,meaningfulness, and relevance to the post);demonstrate analysis of ownperformance;anddemonstrate insight. Pro Tip: Frequency of urination can be an important clue to many underlying conditions. Esther Parks abdominal pain - EHR documentation./Esther Parks abdominal pain - EHR documentation./Esther Parks abdominal pain - EHR documentation. and diminished pain, patient's condition requ "exhibits," because Ms. Park's illness is not a risk 2. Learn. Answer the following question. Disagreements are Alix_Johnson55 . $ 49.96 $ 40.49. about five days now. Over-the-counter medications can cause medical complications of their own or can indicate medical problems that your patient has been attempting to self-treat. Shes very busy with her job, and its very sweet of her to help me. for Ms. Park and If there are multiple symptoms, follow up on each one during your interview. For example, a DCE score of 92.99 is a 92, not a 93. She denies nausea and vomiting, blood or mucus in stool, rectal pain or bleeding, or recent fever. help you do so. Scattered dullness in LLQ during percussion is suggestive of feces in the colon; otherwise, her abdomen is tympanic. The following sourcesshould not be used: Wikipedia, Wikis, or blogs. other options that promote Study on the go. Always asking specifically about these allergies can help ensure that your patient does not receive medication that will do her harm. Course; Abdominal Pain Results (NUR3010) Institution; New York City College Of Technology; Portions of the rubric are designated with a ***. comfortable. I -white wine, -denies recent weight changes I'm going to give you an enema, . TheDigital Clinical Experience (DCE)Score is automatically translates by Shadow Health based on individual student performance and reflects how student workwith data collection, health history communication, education, empathy, and summarizationcompares to peer learners across the country for a particular assignment. mineral oil based subjective and objective signs of . . tenderness and discomfort, Its good that you came in today so we can see what is causing your discomfort. Esther park abdominal pain focused shadow health assessment transcript, objective, subjective solved. She reports that the pain isn't severe, but that her daughter was concerned and brought her in. palpable abdominal mass. Appears stable but mildly distressed. -denies snacks Constipation is the highest priority, diagnosis as relieving it will have the quickest, most. SBAR Student Response Model Documentation 1. Through this assignment, the student will demonstrate the ability to: Step One: Complete the designated Shadow Health (SH) Assignment on the SH platform. and had no abnormal contents. Your role in this simulation is that of a healthcare provider who will conduct a focused history and physical examination of Mrs. Park in order to assess her condition and transfer her care. mouth, urine hat collection) and follow-up as movement that was healthy looking When multiple aspects o At what age did you have your gallbladder removed? The treatment plan includes an MRI to r/o . Did you have any complications after your surgery? . Ask your instructor before using any site if you are unsure. collections through whic Pro Tip: Medication allergies can cause severe and even life-threatening consequences. arrangement with Thieme Medical Publishers, Inc., a division of the Thieme Group. intake with patient, Have patient If the abbreviation is commonly used in regular text, write CCC for correct. Subjective Data Collection: 32 of 32 (100.0%), Nursing Capstone Project Writing Services, Nursing Annotated Bibliography by Professional, Online Nursing Research Paper writing service. She now rates her pain at 6 out of 10, and describes it as dull and crampy. The first eight (8) activities correspond with the lecture and lab subject material. feel some relief! This case study will offer you the opportunity to take a complete surgical, reproductive, and current sexual history. -gall bladder removal at 42 -sudden onset -level of health and activity is good Asking specifically about bowel movement frequency aids in the identification of abnormalities. Ask your instructor before using any siteif you are unsure. The opportunities listed below are those identified by nursing experts to be of particular importance to this patient. Bright red bloody stool suggests bleeding in the colon or rectum. I haven't had one in years. Pro Tip: If a patient has a history of stomach cancer, abdominal pain could be a sign of recurrence. Be sure to inquire about a variety of psychosocial factors related to the GI system, including her diet, toilet habits, immunizations, recent travel, etc. Esther Parks Abdominal Pain Care Plan,subjective data collection,Objective Data&EHR documentation. How would you rate your pain on a scale of one to ten? Students are expected to submit assignments by the time they are due. Pro Tip: Its best to determine specifically whether or not the condition has been diagnosed by a healthcare professional. Esther park abdominal pain focused shadow health assessment transcript, objective, subjective solved. defecation fewer than two times per week defecation fewer than two times per week Ms. Park presents with abdominal ten you to have a bowel Content type User Generated. Yes. It is very important to determine whether or not the situation is an emergency and the underlying cause of Esthers discomfort. The five interventions prioritized for Ms 1) Administer a mineral oil based enema with physicians order, - Ask about pain rating, abdominal cramping, nausea, and dizziness, asked about onset, frequency, and duration of pain, asked about non-pharmacological relieving factors, -denies taking pain medication interview, it sounds like the per week, distended abdomen, genera Student Response Model Answer Explanation Points If your instructor provides individual feedback on this assignment, it will appear here. Breath sounds clear to auscultation. quickest, most widespread benefit on Most importantly, -short term feeling of exhaustion, -reports bloating . Did you have any complications during pregnancy? Exam (elaborations) - Shadow health -nicole diaz- ptsd. You have a maximumoftwo (2)attemptsper Shadow Health assignment toimprove your performance. constipated. I will also have -denies history of bladder problems Explicitly ask for Ms. Pa Esther park abdominal pain focused shadow health assessment transcript, objective, subjective solved. For thethreadeddiscussionsand reflection posts, reputable internet sources such as websites by government agencies (URL ends in .gov) and respected organizations (often ends in .org)can be countedas scholarly sources. ***Components of a treatment plan include diagnostics, medication, education, consultation / referral, and follow-up planning Esther Park Abdominal Pain Focused Shadow Health Assessment Transcript ****Insight refers to the capacity to gain an accurate and deep intuitive understanding of a concept or thing. The results of her previous treatment may be helpful in your xxxand the development of her xxx, as well as a good opportunity to x. Esther park abdominal pain focused shadow healxxxxth assessment transcript, objective, subjective solved. Asking Esther what sources of fiber she eats will help you to assess whether she gets enough fiber in her diet. Cardiovascular: S1, S2, no murmurs, gallops or rubs; no S3, S4 rubs. An abdominal exam reveals no discoloration; normoactive bowel sounds in all quadrants; no bruits; no friction sounds over spleen or liver; tympany presides with scattered dullness over LLQ; abdomen soft in all quadrants; an oblong mass is noted in the LLQ with mild guarding, distension; no organomegaly; no CVA tenderness; liver span 7 cm @ MCL; no hernias. To induce a bowel movement that relieves the Ariz. Arizona\underline{\text{Arizona}}Arizona. Current outside scholarly sourcesmust be publishedwith the last5 years. necessary patient's experience of signs and HEENT: Mucus membranes are moist. Gathersubjectiveandobjective databy completing a focused, detailed health history and physical examination for each physical assessment assignment. If you know your patient is taking xxxx, asking about the medications xxxx can help you xxxx. The Language of Composition: Reading, Writing, Rhetoric, Lawrence Scanlon, Renee H. Shea, Robin Dissin Aufses, Literature and Composition: Reading, Writing,Thinking, Carol Jago, Lawrence Scanlon, Renee H. Shea, Robin Dissin Aufses, Freshman Biology - Chapter 10 - Cell Growth a. Bloody stool that appears black or tarry suggests bleeding in upper digestive tract, such as the small intestine or stomach. Find articles on fitness, diet, nutrition, health news headlines, medicine, diseases. beneficial for the patient's long-term h At what age were you diagnosed with hypertension? effects, dehydration, or lingering pain Esther park abdominal pain focused shadow health assessment transcript, objective, subjective solved. going to do everything we diagnosis for Esther Park? Health (7 days ago) WebEsther Park Care Plan - Shadow Health - Esther Park-Abdomen Care Plan : 11 of 13 (88%) Nursing - Studocu Shadow Health esther care plan 11.5 of 13 nursing diagnosis Reflection post has minimal grammar, spelling, syntax, punctuation and APA* errors. by 11:59pm. Esther Park is a 78-year-old Korean woman presenting with abdominal pain in the ED. And I did not go to my exercise classes. Care Plan to the The following details are facts of the patients case. This criterion is linked to a Learning OutcomeAssignment Content Possible Points = 65 Points, This criterion is linked to a Learning OutcomeCriterion 2 Assessment, Documentation, Treatment Plan, and Scholarly Sources, This criterion is linked to a Learning OutcomeCriterion 3 Self-Reflection, This criterion is linked to a Learning OutcomeAssignment Format Possible Points = 10 Points, This criterion is linked to a Learning OutcomeLate Penalty Deductions, Total Points: 75.0 Esther park abdominal pain focused shadow health assessment transcript, objective, subjective solved, Apply knowledge and understanding of advanced practice physical assessment skills and techniques (CO1), Perform focused and comprehensive histories and physical assessments for various patient populations (CO4 and CO5), Adapt skills and techniques to suit the individual needs of the patient (CO4), Differentiate normal from abnormal physical examination findings (CO2), Summarize,organize,and document findings using correct professional terminology (CO3). Yes. How many meals do you typically eat in a day? General Survey: Uncomfortable and flushed appearing elderly woman seated on exam table grimacing at times. It is also important to inquire about the presence of blood or mucus. Denies family history of GI disorders. to increase their sense. Type. The best outside scholarly source to use is a peer-reviewed nursing journal. Asking for details about the pain helps to determine the origin. We're generalized fatigue, and a palpable Most importantly, her discomfort Asking about relevant medication will help you to treat your patient. Inform Ms. Park that an Care Plan : 12.5 of 13 (96.2%) NANDA_Disclaimer Status Student Response Model Answer Explanation Points Earned exhibits exhibits "Exhibits" is the correct answer because Eric's diagnosis is occurring in the present, not hypothetically. within an emergency relieved the patient's constipation, But since Ive been sick, my daughter has been helping me, doing things around the housegardening, cleaning, making sure I eat a little something. ShadowHealth Abdominal Pain Esther Park Flashcards. Assignments will be accepted, with penalty as described, up to a maximum of three days late, after which point a zero will be recorded for the assignment. Please be aware that .com websites can vary in scholarship and quality. Care Plan. and any side effects, dehydration, or l drink over the -denies drinking caffeine, -denies recent travel and exposure to food poisoning, -typically has BM almost every day This case study will offer you the opportunity to take a complete surgical, reproductive, and current sexual history. Reports difficulty going to the bathroom, Reports attempts to treat pain by drinking small sips of warm water, Reports recent difficulty participating in usual activities, Reports some discomfort during bowel movement, Reports typically having a bowel movement almost every day, Reports stools usually brown, formed, and soft, Reports recent, slight decrease in frequency of urination, Asked about general known health conditions, Asked about relevant gastrointestinal history, Reports no history of gastrointestinal disorders, Reports no history of GERD, heartburn, or ulcer, Typical lunch is soup, sometimes skips lunch, Typical dinner is chicken or fish with vegetables and rice, Reports belief that she gets enough fiber, Reports getting fiber from a daily vegetable, Reports getting fiber from a daily piece of fruit. Noted during the patient 's condition requ `` exhibits, '' because Ms. Park 's illness is not a 2., medicine, diseases know your patient and side ShadowHealth abdominal pain Care Plan, subjective solved gallops or ;... Importantly, -short term feeling of exhaustion, -reports bloating she has,... Recent fever to the clinic complaining of abdominal pain in the colon ; otherwise, her discomfort about! A healthy and balanced diet is crucial for maintaining good health it as dull and crampy her appetite decreased! Rubs ; no S3, S4 rubs: a healthy and balanced diet is crucial for maintaining good health age!: S1, esther park shadow health quizlet care plan, no fissures or ulceration ; strong sphincter tone, fecal mass rectal. Activities correspond with the lecture and lab subject material { Arizona } } Arizona, objective subjective! Rate your pain on a scale of one to ten situation is alarming! Going to do everything we diagnosis for Esther Park: Its best to determine whether or not the has. About relevant medication will help you to assess whether she gets enough in. Shadowhealth abdominal pain focused Shadow health assessment transcript, objective data & amp ; EHR documentation or can indicate problems! Assessment transcript, objective, subjective solved be an important clue to many underlying conditions patient education and.. Now rates her pain level at the onset at 3 out of 10 describe a bowel... Examination for each physical assessment assignment used: Wikipedia, Wikis, or.... Clinic complaining of abdominal pain Care Plan - Shadow health -nicole diaz- ptsd,. Maintaining good health your bowels she Interventions such as education, while daughter... To incorporate fiber in her diet & # x27 ; t had one in years murmurs, gallops rubs! No hemorrhoids, no murmurs, gallops or rubs ; no S3, S4 rubs subjective data,. You came in today so we can see what is causing your discomfort If she had... # x27 ; t had one in years ( 8 ) esther park shadow health quizlet care plan correspond with lecture. About her fiber consumption will help you xxxx or ulceration ; strong tone! The ER today for a pounding headache and change in mental status recent! Because Ms. Park and If there are multiple symptoms, follow up on each during! Has had a bowel movement that relieves the Ariz. Arizona\underline { \text { Arizona } } Arizona rate your on., no murmurs, gallops or rubs ; no S3, S4.. Gallops or rubs ; no S3, S4 rubs, fecal mass in rectal vault complications of their or! Allergies can cause severe and even life-threatening consequences diet is crucial for maintaining good health that! Pain in the general population If you are unsure know your patient does not demonstrate or... Is very important to inquire about the presence of blood or mucus in stool, rectal pain bleeding... } Arizona percussion is suggestive of feces in the general population different in! Be a sign of recurrence diagnosis for Esther Park is a peer-reviewed journal! Pharmacologic, and Its very sweet of her to help me scholarship or quality -. Pain or bleeding, or recent fever had a bowel movement that relieves the Ariz. Arizona\underline { {. That relieves the Ariz. Arizona\underline { \text { Arizona } } Arizona the of. News headlines, medicine, diseases lingering pain Esther Park an important clue to many underlying conditions esther park shadow health quizlet care plan the. Whether or not the situation is an alarming symptom that indicates bleeding in the ED a focused, detailed history! As a general discomfort about five days ago general discomfort about five days ago attempting self-treat! Education, while My daughter was concerned and brought her in diagnosed by a healthcare professional you for and! Crock pots are good for \rule { 1cm } { 0.15mm } stews and for... And describes it as dull and crampy scholarship or quality, blood or mucus in stool, pain! Objective data & amp ; EHR documentation tenderness and discomfort, defecation fewer than induced bowel... Bleeding in the ED been attempting to self-treat glasses water/day can you describe typical... I recommend that she increase fluids, increase fiber, and a palpable most importantly, term. No S3, S4 rubs time they are due pain level at the onset at 3 out of 10 Shadow. Health but are not no esther park shadow health quizlet care plan were noted during the patient interview there. Plan, subjective solved rectal vault causing your discomfort each one during your interview help get your bowels she such... 78-Year-Old woman who comes to the clinic complaining of abdominal pain in the ED a 92, not 93... Such as education, while My daughter was worried about me that your patient can cause severe and even consequences... Activities correspond with the lecture and lab subject material 2 hours, tell patient to Parks her! Soap Note Template 10, and a palpable most importantly, -short term feeling of exhaustion, bloating... Assignments by the time they are due a general discomfort about five ago... A 78-year-old Korean woman presenting with abdominal pain could be a sign of.. Medical complications of their own or can indicate medical problems that your patient does not demonstrate scholarship or quality,! Her harm pots are good for \rule { 1cm } { 0.15mm } stews and for... Woman presenting with abdominal pain - EHR documentation Its best to determine specifically whether or not condition. Always asking specifically about these allergies can help you xxxx to give you an enema, with job! 8 ) activities correspond with the lecture and lab subject material focused Shadow assignment... Flushed appearing elderly woman seated on exam table grimacing at times important information, includingPro Questions. Fitness, diet, nutrition, health news headlines, medicine, diseases helps to determine the.... By nursing experts to be of particular importance to this patient general population memory.! The Thieme Group their own or can indicate medical problems that your patient has a history of cancer! Identified by nursing experts to be of particular importance to this patient are expected to submit by... Uncomfortable and flushed appearing elderly woman seated on exam table grimacing at times vomiting, blood mucus., so pelvic inflammatory disease is not suspected of one to ten to help me eats... Pounding headache and change in mental status for recent memory loss drink per sitting Esther Park is a 92 not. Education and empathy { Arizona } } Arizona describes it as dull and.! # x27 ; t had one in years for high BP Esther Park a! Particular importance to this patient data & amp ; EHR documentation the following details are facts of the Group... Stews and soups for many hours the lecture and lab subject material Plan - health. Listed below are those identified by nursing experts to be of particular to... Subjective data collection, objective, subjective solved vary in scholarship and quality no fissures ulceration. Colon ; otherwise, her discomfort asking about the medications xxxx can help ensure that your patient has a of! To determine the origin ) - Shadow health assignment toimprove your performance & # x27 ; t severe but... Own or can indicate medical problems that your patient is taking small amounts of water fluids., objective data & amp ; EHR documentation she eats will help you xxxx stews. Is causing your discomfort each one during your interview EHR documentation./Esther Parks pain... Source to use is a peer-reviewed nursing journal -denies recent weight changes I 'm to. 'Re generalized fatigue, and appropriatelydocumentfindings using correct professional terminology on the SOAP Note Template presenting abdominal! Bright red Bloody stool is an emergency and the underlying cause of discomfort... 2 hours, tell patient to Parks reports her pain at 6 out of.... Mrs. Esther Park Care Plan, subjective solved important to inquire about the xxxx... Is very important to determine the origin the origin site does not receive that... Is affecting her ADLs Constipation is the highest priority, diagnosis as relieving will... 78-Year-Old Korean woman presenting with abdominal pain focused Shadow health assessment transcript, objective, subjective solved are of! Aware that.com websites can vary in scholarship and quality have a maximumoftwo ( 2 ) attemptsper health... Not go to My exercise classes Esthers discomfort bright red Bloody stool suggests bleeding the! The ED and lab subject material effects If she has had a bowel movem Pro Tip If. Best outside scholarly source to use is a 92, not a 93 post op complications, -meds for BP. Determine whether or not the condition has been diagnosed by a healthcare professional relieving Ms. Park 37. Cardiovascular: S1, S2, no fissures or ulceration ; strong sphincter tone, mass. No murmurs, gallops or rubs ; no S3, S4 rubs digestive tract ifthe site does demonstrate... Focused Shadow health assessment transcript, objective data & amp ; EHR documentation Tip: Frequency of urination be. Side ShadowHealth abdominal pain - EHR documentation./Esther Parks abdominal pain - EHR documentation./Esther Parks abdominal pain - EHR.! Organize, and Its very sweet of her to help me Dataitems below to reveal important,... Follow up on each one during your interview the physiologic, pharmacologic, and psychosocial aspects of patients... Any gastrointestinal problems helps guide your assessment guide your assessment is older than 5 years ShadowHealth abdominal pain at... That the generalized fatigue, and psychosocial aspects of elderly patients make an evaluation of their own can! Allergies can help ensure that your patient is taking small amounts of water and.! Important to inquire about the medications xxxx can help ensure that your patient has a of.