Health Assessment

Kurt Daniel S. Gianan 2022-01026

BSN-1B February 3, 2022

1. Identify abnormal data and strengths in subjective and objective findings, assemble
cue clusters, draw inferences, make possible nursing diagnosis, identify defining
characteristics, confirm or rule out the diagnoses and document your conclusion.
Mrs. Vera Wagner is a 60-year-old white woman who emigrated from Germany to the
United States at the age of 18. She has come to her primary care physician’s office with her
daughter. She tells you, “My daughter made me come here because I have had bad stomach pains
for about 6 weeks.” After you ask about the character, onset, location, duration, severity, and
pattern of the pain as well as associated symptoms (COLDSPA), such as what relieves the pain
and what functions are affected by pain, you learn the following information. The pain is aching
epigastric pain, fairly continuous, and worse at night. It radiates to her back when she lies down.
The pain gets progressively worse, is not affected by eating, and interferes with her daily
function (it prevented her from attending her grand-son’s birthday party; it also wakes her up at
night). Additionally, Mrs. Wagner admits to loss of appetite, mild nausea, heartburn, and fatigue.
For the past several months she has felt full soon after beginning a meal. She tells you that she
was afraid to tell her doctor this because “He always says I worry too much. “A review of Mrs.
Wagner’s chart discloses that she had four normal vaginal deliveries, several bladder and kidney
infections, a total abdominal hysterectomy at age 50 for uterine fibroids, cholecystectomy at age
55, two episodes of deep vein thrombosis in the past few years, allergy to penicillin, and stomach
sensitivity to medicines (e.g., aspirin). Four years ago, she had gastric endoscopy and upper
gastrointestinal (GI) barium swallow studies for complaints of heartburn and difficulty
swallowing. The results delayed esophageal peristalsis.
Mrs. W. takes estrogen and calcium daily (in the form of Tums) as recommended by her
physician as a source of hormone and calcium after surgical menopause. She tells you that she
has recently started to take acetaminophen once-sometimes twice- daily in the hope that this will
relieve her pain. She has had mild temporary relief as a result.
Mrs. W’s family history reveals that her mother died at age 58 from ‘liver problems
having half her stomach removed.” She says she does not smoke, drink, or use illegal drugs. She
says that she has eaten the same diet all her life. “I eat good German food, a lot of potatoes and
meats. My children tell me I should eat more vegetables and drink more water, but I don’t like
fruits and vegetables and Id rather drink coffee. “In response to your question about exercise,
you learn that Mrs. W. walks to the post office ever day, and “I pick up after my husband around
the house- does that count?” You comment that Mrs. W. looks upset, and she tells you that she is
very concerned about her pain. “I always been strong and healthy, and now I am getting old and
sick. It is depressing.”
Your physical assessment reveals a firmly palpable left supraclavicular node,
approximately 2 cm in diameter, nonmobile, and nontender, as well as the following abdominal
findings: abdomen round and symmetric, hysterectomy scar striae, umbilicus in the middle
without inflammation or herniation, slight midline pulsation in the epigastrium. Soft bowel
sounds are heard in all four quadrants; no audible bruits. Generalized tympany percussed
throughout; span of liver dullness is 13 cm over the MCL, splenic dullness at the 10th intercoastal
space (ICS). The abdomen is soft and tender to palpation in the epigastrium; the liver edge
descends 2 cm below the right coastal margin (RCM) on deep inspiration; no splenomegaly is
noted.

Subjective Data:
 Bad stomach pain
 Pain is aching epigastric pain, fairly continuous, and worse at night
 Radiates to the back when she lies down
 The pain gets progressively worse
 Not affected by eating and interferes with her daily function (also wakes her up at night)
 Loss appetite
 Mild nausea
 Heartburn
 Fatigue
 Felt full soon after beginning of meal
 Several bladder and kidney infections
 Abdominal hysterectomy at 50 for uterine fibroids
 Cholecystectomy at age of 55
 2 episodes of deep vein thrombosis
 Allergy to penicillin
 Stomach sensitivity to medicine (like aspirin)
 She had four normal vaginal deliveries
 Has delayed esophageal peristalsis.
 Takes estrogen and calcium daily (in the form of Tums) as recommended by her
physician as a source of hormone and calcium after surgical menopause
 Started to take acetaminophen once-sometimes twice- daily and had a temporary relief as
a result
 Do not like to eat fruits and vegetables and rather drink coffee than water

Objective Data:
Physical assessment reveals a firmly palpable left supraclavicular node, approximately 2
cm in diameter, nonmobile, and nontender, as well as the following abdominal findings:
abdomen round and symmetric, hysterectomy scar striae, umbilicus in the middle without
inflammation or herniation, slight midline pulsation in the epigastrium. Soft bowel sounds are
heard in all four quadrants; no audible bruits. Generalized tympany percussed throughout; span
of liver dullness is 13 cm over the MCL, splenic dullness at the 10th intercoastal space (ICS). The
abdomen is soft and tender to palpation in the epigastrium; the liver edge descends 2 cm below
the right coastal margin (RCM) on deep inspiration; no splenomegaly is noted.
Cue clusters:
 Bad stomach pain
 Loss appetite
 Mild nausea
 Heartburn
 Fatigue
 Difficulty of swallowing

Draw Inferences:
The patient may have stomach cancer, also known as gastric cancer, a cancer that
develops from the lining of the stomach. Early symptoms that may include heartburn, upper
abdominal pain, nausea, and loss of appetite. Later signs and symptoms may include difficulty
swallowing which all have experienced by the patient. Plus, the patient had several bladder and
kidney infections which may be a risk factors that leads her to have a stomach cancer.
Nurse must observe and document location of pain, scale (1 to 10) and character of the
pain. Promote bed rest, control environmental temperature, encourage the patient to remain in the
position where she is comfortable and use of relaxation technique. Promotes GI muscle
relaxation, thereby reduces abdominal cramps. Administer medications that is good for stomach
pain. The client must eat smaller meals and maintaining an adequate calorie intake by adding
calorie-dense foods. The client must eat high protein foods and high fiber foods.
Acetaminophen can also help in maintaining the pain in stomach. Also, the patient must avoid
anti-inflammatory medicines such as aspirin.

List possible nursing diagnosis:

The patient may have a warning signals of stomach cancer due to some symptoms like
the bad stomach pain, loss appetite, mild nausea, heartburn, fatigue, and difficulty of swallowing.
Or, the patient may have metastatic tumor because in the physical assessment, firmly palpable
left supraclavicular node may be a warning for the metastatic tumor.

Check for defining characteristics:

 Stomach pain
 Loss appetite
 Mild nausea
 Heartburn
 Fatigue
 Several bladder and kidney infections
 Allergy to penicillin
 Stomach sensitivity to medicine
 Eating unhealthy foods
 Had a family history of his parents died from liver problems
  Had gastric endoscopy and upper gastro intestinal barium swallow studies for complaints
of heartburn and difficulty of swallowing. The result delayed esophageal peristalsis
 firmly palpable left supraclavicular node
 slight midline pulsation in the epigastrium
 soft bowel sounds are heard in all four quadrants

Confirm or rule out diagnosis:

The client has stomach cancer due to the symptoms stated and observed in the patient.
Also, it is stated that she had cholecystectomy at age of 55. She may be having some disease
before that affects his gastrointestinal area that leads to stomach cancer.

Document conclusions
Nursing diagnosis that is appropriate for this client include:
-Common tests and procedures in stomach cancer involves blood test to check for
anemia and infections. Also, endoscopy, by inserting a thin tube with a tiny camera into the
stomach to examine the inside. And, barium swallow. A series of X-rays of the stomach is
taken after you swallow liquid barium to look for the stomach cancer. Or, by biopsy, a small
sample of the mass is sent for microscopic examination to check for the type and severity of
cancer. Laparoscopy, to check if the cancer has spread beyond the esophagus or stomach.
The client must maintain diet and eat healthy food recommended for her recovery. Like foods
high in fiber and protein. The patient must remain in the position where she is comfortable. Also,
the patient must take appropriate medicines like the acetaminophen to maintain the pain in her
stomach. Chemotherapy drugs used to kill cancer cells and immunotherapy that uses antibodies
to identify and kill cancer cells can also be effective.

Potential collaborative problems include the following:

-Unhealthy food and diet intake of the patient can be a potential collaborative problem.
The patient has a family history that her mother has liver problems. Plus, several bladder and
kidney infections in the patient. She also has a history of cholecystectomy and total abdominal
hysterectomy. Two episodes of deep vein thrombosis and the patient had gastric endoscopy.