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12.4: Documentación de muestra

Última actualización

30 oct 2022
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- 12.3: Evaluación Gastrointestinal y Genitourinaria
- 12.5: Lista de verificación para la evaluación abdominal

Ernstmeyer & Christman (Eds.)
Chippewa Valley Technical College via OpenRN

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Muestra de documentación de hallazgos esperados

El paciente niega dolor abdominal, náuseas, vómitos, distensión abdominal, estreñimiento, diarrea, dolor urinario, urgencia o frecuencia, cambio en el apetito, intolerancia alimentaria, disfagia, o antecedentes personales o familiares. El contorno abdominal es plano y simétrico. No se observaron lesiones visibles, pulsaciones o peristalsis. Sonidos intestinales presentes y normoactivos. Paciente niega dolor con palpación; no se notan masas.

Documentación de muestra de hallazgos inesperados

El paciente reporta dolor abdominal generalizado, junto con náuseas y vómitos durante los últimos dos días. El abdomen está ligeramente distendido. Intestino suena hipoactivo en los cuatro cuadrantes. Dolor reportado a 7/10 y resguardo observado con palpación del RLQ. El Dr. Smith notificó a las 0730.

Muestra de documentación de hallazgos esperados

Documentación de muestra de hallazgos inesperados

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