Introduction
During this week’s clinical experience, I encountered a patient with complaints of persistent abdominal pain and digestive issues. The patient, a 60-year-old female, presented with signs and symptoms (S&S) of intermittent pain in the upper abdomen, bloating, and occasional nausea. As an advanced practice nurse, I conducted a comprehensive assessment to diagnose and develop a plan of care for the patient.
Assessment
The patient’s initial assessment included a detailed medical history, physical examination, and laboratory tests. The patient reported experiencing the symptoms for the past six months, and the pain was aggravated after meals. She denied any recent weight loss or changes in bowel movements.
On physical examination, there were no significant abnormalities noted. Laboratory tests, including complete blood count, liver function tests, and pancreatic enzyme levels, were within the normal range. However, an abdominal ultrasound revealed mild gallbladder wall thickening and the presence of gallstones.
Plan of Care
Based on the assessment findings, the plan of care involved the following:
Pain Management: The primary focus was to manage the patient’s abdominal pain and discomfort. Non-steroidal anti-inflammatory drugs (NSAIDs) were prescribed for pain relief as needed.
Dietary Modifications: Given the presence of gallstones, dietary modifications were essential to prevent exacerbation of symptoms. The patient was advised to follow a low-fat diet, avoiding fried and greasy foods.
Monitoring and Follow-Up: The patient was scheduled for regular follow-up appointments to monitor symptom progression and ensure treatment effectiveness.
Differential Diagnosis
The patient’s presentation of abdominal pain and digestive issues necessitated considering multiple possible differential diagnoses:
Gallstones (Cholecystolithiasis): The presence of gallstones and gallbladder wall thickening on abdominal ultrasound supported this diagnosis. Gallstones can lead to intermittent abdominal pain and digestive disturbances (Gurusamy et al., 2018).
Gastric Ulcer: Although the patient did not report specific symptoms of peptic ulcer disease, the abdominal pain after meals and bloating raised the possibility of a gastric ulcer. Further evaluation, such as an upper endoscopy, was considered to rule out this diagnosis.
Gastroesophageal Reflux Disease (GERD): GERD could cause upper abdominal pain, bloating, and occasional nausea. However, as the patient did not complain of heartburn or acid regurgitation, GERD was considered less likely.
Health Promotion Intervention
To promote the patient’s overall health, a health promotion intervention focused on dietary education was implemented. The patient was educated on the importance of a low-fat diet to manage gallstone-related symptoms. By making dietary modifications, the patient could prevent symptom exacerbation and improve her overall well-being.
Advanced Practice Nurse Insights
Through this clinical experience, I gained valuable insights as an advanced practice nurse. One crucial aspect was the significance of conducting a thorough assessment to reach an accurate diagnosis. The comprehensive evaluation helped identify the underlying cause of the patient’s symptoms, allowing for targeted and effective treatment.
Moreover, I learned the importance of patient education in promoting health and preventing complications. By providing dietary education, I empowered the patient to actively participate in managing her condition and maintaining her overall health.
Research-Guided Plan of Care
The plan of care aligns with the guidelines provided by the American College of Gastroenterology (ACG) for the management of gallstone-related symptoms (ASGE Standards of Practice Committee et al., 2019). The ACG recommends a low-fat diet and pain management for patients with uncomplicated gallstone disease. Regular monitoring and follow-up are also emphasized to assess treatment efficacy and ensure patient well-being.
Conclusion
This week’s clinical experience provided valuable insights into patient assessment, diagnosis, and plan of care. By conducting a comprehensive evaluation, I successfully diagnosed gallstone-related symptoms in a patient and developed a plan of care tailored to her needs. The health promotion intervention focused on dietary education empowered the patient to actively participate in managing her condition and enhancing her overall health. Through this experience, I reinforced the importance of evidence-based practice, patient education, and regular follow-up for optimal patient outcomes.
References
ASGE Standards of Practice Committee, Qumseya, B. J., Sultan, S., Bain, P., Jamil, L. H., Trindade, A. J., … & Siddiqui, U. D. (2019). ASGE guideline on the role of endoscopy in the evaluation and management of choledocholithiasis. Gastrointestinal Endoscopy, 89(6), 1075-1105.
Gurusamy, K. S., Davidson, C., & Gluud, C. (2018). Intervention for gallstones (Review). Cochrane Database of Systematic Reviews, 2018(10).
