I need a document I can go off of. I have not done this type before and can’t find a good ‘guide’. Here is the scenario and it can have a bunch of…

Question Answered step-by-step I need a document I can go off of. I have not done this type beforeand can’t find a good “guide”. Here is the scenario and it can have a bunch of made up information along with this given information. Its a creative scenario along with info given on the patient. Perform a history of an abdominal problem and perform an assessment of the gastrointestinal system. Document your subjective and objective findings, identify actual or potential risks. SOAP documentation format. Subjective: Mr. Chevy, a 46-year-old Caucasian male Admitted diagnosis:gastrointestinal (GI) bleed Medications include omerorazole, thiamine, vitamin b, and folate supplements. Allergies to morphine, ibuprofen, and tetracyclineSubstance use- alcohol Currently: Mr. Chase reports that five minutes prior to nurse entering the room, he vomited bright red blood into the garbage can. Patient states “I just felt it coming on fast. I knew I shouldn’t have eaten that food.” ask him more OLDCARTS about his vomiting/abdominal systemPain: 4/10- Ask OLDCARTS about this He also reports feeling nauseous, fatigued, and anxious. ObjectiveVital signs: Oral temp 36.5 C, HR 124 BPM, RR 24 and BP 100/62 mm Hg. SpO2 93%. Weight 55kg (last weight 65kg). Height 178 cm.Inspection: Abdomen distended. Document rest of inspection as expected finding. Auscultation- Bowel sounds hyperactive in all four quadrants. Document rest of auscultation exam as expected findings.Palpation-Abdomen firm and slightly tender in all quadrants. Other palpation documentation should reflect expected findings. Health Science Science Nursing NUR 2180 Share QuestionEmailCopy link Comments (0)