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, 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.”
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Question: What is the importance of documenting subjective and objective findings in a medical assessment of the gastrointestinal system?
Answer: Documenting subjective and objective findings is crucial in a medical assessment of the gastrointestinal system as it provides a comprehensive understanding of the patient’s health status. Subjective findings refer to what the patient reports or feels, and objective findings are observable measures. By documenting both aspects, healthcare professionals can gather critical information and identify any potential risks or underlying medical conditions. This information is useful for the diagnosis and treatment of abdominal problems and ensures that patients receive appropriate care.