NUR:2180 Module 04 Lab Assignment
Documentation of an Assessment of the Gastrointestinal System
Crohn’s Disease
Patient: Age: 20 Gender: Female
Reason for visit: stomach pain, nausea, diarrhea
1. Health History
1. Any change in appetite? Loss? Yes, patient has a loss of appetite, she states that she
has Crohn’s disease and when she has a flare up, she doesn’t feel like eating.
2. Any difficulty swallowing? No
3. Any foods you cannot tolerate? Patient is on a low-residue diet.
4. Any abdominal pain? Yes, patient states she has pain and cramping around her belly
button and in her lower-right abdomen.
Patient states she always has some pain and cramping but, the pain has gotten worse.
Patient stated that for the past 2 days, she gets severe pain and has vomited about an
hour or two after eating.
The patient rates the pain around a 5 as long as they don’t eat. When the patient eats,
the pain goes up to an 8/10 an hour or two after eating. It stays at an 8 for several
hours. The pain is accompanied by nausea, sometimes vomiting and diarrhea.
Patient states diarrhea is a 7 on the Bristol Stool chart. Stool is watery with no blood
present. Vomiting is watery with a few larger pieces, no blood is present.
The patient states that the things that make it better are not eating, using a heating
pad and laying down.
5. Any nausea or vomiting? Yes, patient states she threw up a few times at home and
feels nauseated. Her nausea increases after eating and she throws up sometimes.
Ginger Ale helps her nausea so that she doesn’t throw up but, the nausea is still there.
6. How often are bowel movements? Patient states has 4 or more bowel movements a
day
7. Any past history of GI disease? Yes, patient was diagnosed with Crohn’s disease in
2010.
8. What medications are you taking?
Humira Pen 40mg/0.4 ml
Budesonide EC 3mg capsule: 1 capsule 3x/day (Entocort) steroid
Azathioprine 2 mg tablets: 1 tablet/day
Dicyclomine 10 mg capsule: 1 capsule 3x/day
Ondansetron ODT 8mg Tablets Dissolve 1 tab by mouth 3x/day as needed (for
nausea)
, CHOLESTYRAMINE PACKET Powder in Packet: 1 Packet Mixed With Water Or
Non-carbonated Drink Twice A Day As needed for diarrhea.
Alprazolam 1mg tablets 1x/day
Zolpidem Tartrate ER 6.5 mg Tablet : 1 tab at bedtime for sleep
Ibuprofen 800 mg tablets: take 1 tablet 3x/day with food or milk as needed
Bupropion HCL XL 300 mg tablets: 1 tablet/day
Vitamin D3 50,000 unit capsules: 1x/week
Multi-vitamins (OTC)
9. What have you eaten in the past 24 hours?
Breakfast: plain toast and Grape Gatorade
Snack: crackers
Lunch: chicken noodle soup, crackers, Ginger ale
Snack: pretzels
Dinner: chicken noodle soup and crackers, Gatorade
ll. Physical Examination
A. Inspection
Contour of abdomen: contour of abdomen is protuberant.
Skin color and condition: skin is smooth and color is consistent with the rest of the
body. No lesions were present. Patient has 2 scars from previous surgeries on Right
Lower Quadrant.
Pulsation or movement: no visible pulsation or movement
Umbilicus: midline and inverted
State of Hydration and nutrition: patient is dehydrated, poor nutrition
Person’s facial expression and position in bed: patient is curled up on side in bed
guarding the lower right side of their stomach and grimacing. Patient’s face is red,
flushed and warm.
B. Auscultation
Bowel Sounds: Hyperactive bowel sounds
Vascular sounds: no vascular sounds
C. Percussion: The abdomen is tympanic in all 4 quadrants; the liver is 10 cm in the
midclavicular line and 7cm in the midsternal line (Normal liver span). There was no
costovertebral angle tenderness noted on percussion.
D. Palpation:
Light palpation of the Upper and Lower left quadrants and upper right quadrant with a normal
muscle wall, no masses, tumors, enlarged organs or tenderness.
Documentation of an Assessment of the Gastrointestinal System
Crohn’s Disease
Patient: Age: 20 Gender: Female
Reason for visit: stomach pain, nausea, diarrhea
1. Health History
1. Any change in appetite? Loss? Yes, patient has a loss of appetite, she states that she
has Crohn’s disease and when she has a flare up, she doesn’t feel like eating.
2. Any difficulty swallowing? No
3. Any foods you cannot tolerate? Patient is on a low-residue diet.
4. Any abdominal pain? Yes, patient states she has pain and cramping around her belly
button and in her lower-right abdomen.
Patient states she always has some pain and cramping but, the pain has gotten worse.
Patient stated that for the past 2 days, she gets severe pain and has vomited about an
hour or two after eating.
The patient rates the pain around a 5 as long as they don’t eat. When the patient eats,
the pain goes up to an 8/10 an hour or two after eating. It stays at an 8 for several
hours. The pain is accompanied by nausea, sometimes vomiting and diarrhea.
Patient states diarrhea is a 7 on the Bristol Stool chart. Stool is watery with no blood
present. Vomiting is watery with a few larger pieces, no blood is present.
The patient states that the things that make it better are not eating, using a heating
pad and laying down.
5. Any nausea or vomiting? Yes, patient states she threw up a few times at home and
feels nauseated. Her nausea increases after eating and she throws up sometimes.
Ginger Ale helps her nausea so that she doesn’t throw up but, the nausea is still there.
6. How often are bowel movements? Patient states has 4 or more bowel movements a
day
7. Any past history of GI disease? Yes, patient was diagnosed with Crohn’s disease in
2010.
8. What medications are you taking?
Humira Pen 40mg/0.4 ml
Budesonide EC 3mg capsule: 1 capsule 3x/day (Entocort) steroid
Azathioprine 2 mg tablets: 1 tablet/day
Dicyclomine 10 mg capsule: 1 capsule 3x/day
Ondansetron ODT 8mg Tablets Dissolve 1 tab by mouth 3x/day as needed (for
nausea)
, CHOLESTYRAMINE PACKET Powder in Packet: 1 Packet Mixed With Water Or
Non-carbonated Drink Twice A Day As needed for diarrhea.
Alprazolam 1mg tablets 1x/day
Zolpidem Tartrate ER 6.5 mg Tablet : 1 tab at bedtime for sleep
Ibuprofen 800 mg tablets: take 1 tablet 3x/day with food or milk as needed
Bupropion HCL XL 300 mg tablets: 1 tablet/day
Vitamin D3 50,000 unit capsules: 1x/week
Multi-vitamins (OTC)
9. What have you eaten in the past 24 hours?
Breakfast: plain toast and Grape Gatorade
Snack: crackers
Lunch: chicken noodle soup, crackers, Ginger ale
Snack: pretzels
Dinner: chicken noodle soup and crackers, Gatorade
ll. Physical Examination
A. Inspection
Contour of abdomen: contour of abdomen is protuberant.
Skin color and condition: skin is smooth and color is consistent with the rest of the
body. No lesions were present. Patient has 2 scars from previous surgeries on Right
Lower Quadrant.
Pulsation or movement: no visible pulsation or movement
Umbilicus: midline and inverted
State of Hydration and nutrition: patient is dehydrated, poor nutrition
Person’s facial expression and position in bed: patient is curled up on side in bed
guarding the lower right side of their stomach and grimacing. Patient’s face is red,
flushed and warm.
B. Auscultation
Bowel Sounds: Hyperactive bowel sounds
Vascular sounds: no vascular sounds
C. Percussion: The abdomen is tympanic in all 4 quadrants; the liver is 10 cm in the
midclavicular line and 7cm in the midsternal line (Normal liver span). There was no
costovertebral angle tenderness noted on percussion.
D. Palpation:
Light palpation of the Upper and Lower left quadrants and upper right quadrant with a normal
muscle wall, no masses, tumors, enlarged organs or tenderness.
