The Omnibus Budget Reconciliation Act (OBRA), also known as the Nursing Home Reform Act of 1987, has dramatically improved the quality of care in the nursing home over the last twenty years by setting forth federal standards of how care should be provided to residents. 

Gastrointestinal

Acute abdominal pain often represents a spectrums conditions or diseases ranging from self-limited and benign diseases to more serious surgical emergencies. When conducting an assessment on the patient’s abdominal pain, it is crucial to consider some important factors and information. The assessment or evaluation of the abdominal pain requires an approach that rely on the likelihood of a disease, of physical examination, laboratory tests, imaging studies, patient history (Mujagic et al., 2015). The location of the pain in the abdomen is an important starting point because it may guide on further evaluation process (Mujagic et al., 2015). For example, manifestation of right lower quadrant pain usually suggests appendicitis. Various elements of the physical examination and patient’s history are helpful, for example constipation and abdominal distension suggest bowel obstruction, while others have little value. For example, anorexia has insignificant predictive value for appendicitis. Imaging information are also important when conducting abdominal pain assessment. 

Various professional organizations like the American Nursing Association and the American College of Radiology have recommended different imaging studies when assessing abdominal pain depending on the location of the pain (Mujagic et al., 2015). Ultrasonography is always recommended when assessing right upper quadrant pain while computed tomography (CT) scanning is recommended when assessing left and right lower quadrant pain (Mujagic et al., 2015). The other information to collect when conducting an assessment of the abdominal pain is considering special populations like women, especially those at a risk of genitourinary disease that can cause abdominal pain and the senior adults who may present with atypical symptoms of a disease 

When conducting an assessment of the masses in the abdominal region, it is pivotal to identify their possible causes. As a registered nurse, I will conduct an examination of the supraclavicular and inguinal and nodes. In the examination process, I will inspect for the presence of scars, particularly in the umbilicus for the laparoscopy scars. The inspection will also involve identification of distension, pulsation, prominent veins, skin lesions, local swellings, asymmetrical movement, and visible peristalsis. In this case, it is recommended to exclude lesions that are located on the abdominal wall. 

Auscultation of the abdomen is also performed to identify any abnormal or altered bowel sounds, rubs, or vascular bruits (Mujagic et al., 2015). Normal peristalsis usually creates bowel sounds that can be absent or altered in case of a disease. 

Palpation is the last approach that can be utilized when assessing the masses in the abdomen. Warm hands should always be used in the palpation of the abdomen. It is important to check for any rebound tenderness, rigidity, and guarding in these abdominal masses. 

Palpating a mass in the abdomen requires the use of appropriate techniques. I ensured that the patient is positioned in a supine manner with the head and the knees supported. I recorded the patient’s history before performing a thorough inspection and auscultation before palpating the masses in the abdomen. 

Musculoskeletal

Osteoarthritis can be defined as a musculoskeletal condition that results when the protective cartilage responsible for cushioning the ends of the bones wears out over time (Anderson et al., 2018). Osteoarthritis is considered as the most common form of arthritis. Due to its incidence and prevalence rates, osteoarthritis affects millions of people worldwide. Although osteoarthritis can damage any joint, the disorder most commonly affects joints in the hands, spine, knees, and hips. 

Rheumatoid arthritis (RA) is an autoimmune disease that can cause joint pain and damage throughout your body (Anderson et al., 2018). The joint damage that RA causes usually happens on both sides of the body (Anderson et al., 2018). The main similarity between these two musculoskeletal conditions is that both affect the joints. The leading difference is that rheumatoid arthritis is an autoimmune disorder while osteoarthritis is not. 

References

Anderson, J. R., Chokesuwattanaskul, S., Phelan, M. M., Welting, T. J., Lian, L. Y., Peffers, M. J., & Wright, H. L. (2018). 1H NMR metabolomics identifies underlying inflammatory pathology in osteoarthritis and rheumatoid arthritis synovial joints. Journal of proteome research, 17(11), 3780-3790.

Mujagic, Z., Keszthelyi, D., Aziz, Q., Reinisch, W., Quetglas, E. G., De Leonardis, F., … & Masclee, A. A. M. (2015). Systematic review: instruments to assess abdominal pain in irritable bowel syndrome. Alimentary pharmacology & therapeutics, 42(9), 1064-1081.

REPLY 2

Gastrointestinal System

Assessing Abdominal Pain

During abdominal pain assessment, patients should be asked about the severity, onset, quality, and duration of pain and worsening and relieving factors. Information on the pain location is useful at the start of the interview as it guides in further evaluations (Hall, 2017). Also, information about associated signs and symptoms should be gathered to predict specific causes of abdominal pain. Information on the pain’s radiation and movement should also be collected to help rule out some conditions. For instance, abdominal pain associated with appendicitis usually moves from the abdomen’s periumbilical area to the right lower quadrant of the abdomen. Patients should also be asked whether they have been taking nonsteroidal anti-inflammatory drugs recently.

Assessing Masses in Abdomen and Findings Documentation

Assessing masses in the abdomen begins with an inspection, followed by auscultation. Afterward, percussion and palpation follow consecutively. The sequence should not be changed because it may interfere with the frequency of bowel sounds. The patient should empty his or her bladder and lie supine with his or her abdomen exposed. The first step should be to observe the abdomen from the xiphoid process to the symphysis pubis and from side and above and assess any visible mass (Hall, 2017). All the four quadrants of the abdomen should then be lightly percussed, and large dull areas may indicate mass or tumor. If the assessment is normal, then it would be documented as the abdomen is soft, symmetric, and non-tender without distention.

Findings on a Previous Patient

I once encountered a patient who complained of abdominal pain. Upon abdominal assessment, a mass was palpated in her abdomen. The patient had visible bulging in her abdomen. During light percussion, dull sounds were heard over solid abdominal structures like the liver, and air-filled areas like the stomach produced tympany. A large dull area was present in the right upper quadrant, indicating a mass or a tumor.

Musculoskeletal

Osteoarthritis and Rheumatoid Arthritis

 According to Firestein and McInnes (2017), Rheumatoid arthritis is a prolonged immune condition which most affects joints. It is characterized by warm, painful, stiff, and swollen joints. Pain and stiffness aggravate after a rest, and the condition mainly affects the joints in the wrists and the hands, and its effects are experienced bilaterally. Osteoarthritis (OA) is a common form of arthritis that occurs when flexible tissues at the end of bones wear down over time. OA is characterized by joint pain in the lower back, hands, hips, knees, and neck. OA and RA have primary symptoms such as stiff and painful joints, warmth, and tenderness, and during dawns, symptoms become severe (Firestein & McInnes, 2017). Rheumatoid arthritis (RA) and OA are similar in that they are common in women.

 The main difference between RA and OA is their causation. In contrast, RA is an immune disorder that causes fluid to accumulate within joints causing swelling, pain, stiffness, and inflammation. Additionally, OA causes the breaking down of curtilages that cushion joints; thus, it makes bones rub each other, which leads to pain (Firestein & McInnes, 2017). Finally, OA is more prevalent in adults. At the same time, RA attacks all populations, and its symptoms ripple in the whole-body causing symptoms such as muscle aches, fever, excess fatigue, and lumps underneath the skin near joints if the condition is advanced. In contrast, the symptoms of OA are restricted to joints.

References

Firestein, G. S., & McInnes, I. B. (2017). Immunopathogenesis of rheumatoid arthritis. Immunity, 46(2), 183-196.

Hall, C. (2017). Back to basics: Abdominal assessments. Australian Midwifery News, 17(2), 17.