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NURS 6512 Week 6 Assignment 1 Lab Assignment Assessing the Abdomen

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A woman went to the emergency room for severe abdominal cramping. She was diagnosed with diverticulitis; however, as a precaution, the doctor ordered a CT scan. The CT scan revealed a growth on the pancreas, which turned out to be pancreatic cancer—the real cause of the cramping. Because of a high potential for misdiagnosis, determining the precise cause of abdominal pain can be time consuming and challenging. By analyzing case studies of abnormal abdominal findings, nurses can prepare themselves to better diagnose conditions in the abdomen. In this Lab Assignment, you will analyze an Episodic note case study that describes abnormal findings in patients seen in a clinical setting. You will consider what history should be collected from the patients as well as which physical exams and diagnostic tests should be conducted. You will also formulate a differential diagnosis with several possible conditions. To Prepare Review the Episodic note case study your instructor provides you for this week’s Assignment. Please see the “Course Announcements” section of the classroom for your Episodic note case study. · With regard to the Episodic note case study provided: o Review this week’s Learning Resources, and consider the insights they provide about the case study. o Consider what history would be necessary to collect from the patient in the case study. o Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis? o Identifyat least fivepossible conditions that may be considered in a differential diagnosis for the patient. The Assignment 1. Analyze the subjective portion of the note. List additional information that should be included in the documentation. 2. Analyze the objective portion of the note. List additional information that should be included in the documentation. 3. Is the assessment supported by the subjective and objective information? Why or why not? 4. What diagnostic tests would be appropriate for this case, and how would the results be used to make a diagnosis? 5. Would you reject/accept the current diagnosis? Why or why not? Identify three possible conditions that may be considered as a differential diagnosis for this patient. Explain your reasoning using at least three different references from current evidence-based literature. Remember you MUST complete a FULL abdominal exam. Please write this up as a narrative so that you are able to correctly explain your analysis. REQUIRED READINGS Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby. Chapter 6, “Vital Signs and Pain Assessment” This chapter describes the experience of pain and its causes. The authors also describe the process of pain assessment. Chapter 18, “Abdomen” In this chapter, the authors summarize the anatomy and physiology of the abdomen. The authors also explain how to conduct an assessment of the abdomen. Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Advanced health assessment and clinical diagnosis in primary care (6th ed.). St. Louis, MO: Elsevier Mosby. Credit Line: Advanced Health Assessment and Clinical Diagnosis in Primary Care, 6th Edition by Dains, J.E., Baumann, L. C., & Scheibel, P. Copyright 2019 by Mosby. Reprinted by permission of Mosby via the Copyright Clearance Center. Chapter 3, “Abdominal Pain” This chapter outlines how to collect a focused history on abdominal pain. This is followed by what to look for in a physical examination in order to make an accurate diagnosis. Chapter 10, “Constipation” The focus of this chapter is on identifying the causes of constipation through taking a focused history, conducting physical examinations, and performing laboratory tests. Chapter 12, “Diarrhea” In this chapter, the authors focus on diagnosing the cause of diarrhea. The chapter includes questions to ask patients about the condition, things to look for in a physical exam, and suggested laboratory or diagnostic studies to perform. Chapter 29, “Rectal Pain, Itching, and Bleeding” This chapter focuses on how to diagnose rectal bleeding and pain. It includes a table containing possible diagnoses, the accompanying physical signs, and suggested diagnostic studies. Colyar, M. R. (2015). Advanced practice nursing procedures. Philadelphia, PA: F. A. Davis. Credit Line: Advanced practice nursing procedures, 1st Edition by Colyar, M. R. Copyright 2015 by F. A. Davis Company. Reprinted by permission of F. A. Davis Company via the Copyright Clearance Center. These sections below explain the procedural knowledge needed to perform gastrointestinal procedures. Chapter 107, “X-Ray Interpretation: Chest (pp. 480–487) Chapter 115, “X-Ray Interpretation of Abdomen” (pp. 514–520) Note: Download this Student Checklist and Abdomen Key Points to use during your practice abdominal examination. Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Abdomen: Student checklist. In Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby. Credit Line: Seidel’s Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the Copyright Clearance Center. Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Abdomen: Key points. In Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby. Credit Line: Seidel’s Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W.

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lOMoARcPSD|3013804




WEEK 6Assignment 1


Advanced Health Assessment & Diagnostic Reasoning (Walden
University )

, lOMoARcPSD|3013804




Running head: ASSIGNMENT 1: LAB ASSIGNMENT: ASSESSING THE 1




Assignment 1: Lab Assignment: Assessing the Abdomen

Walden University

Advanced Health Assessment

NURS - 6512

, lOMoARcPSD|3013804




ASSIGNMENT 1: LAB ASSIGNMENT: ASSESSING THE 2


Assignment 1: Lab Assignment: Assessing the Abdomen

The objectives of this assignment are to analyze an episodic note case study for the

assessment of the abdomen and gastrointestinal system provided by the professor. The episodic

case note provides subjective and objective information, along with an assessment containing

two diagnoses of left lower quadrant pain and gastroenteritis. This paper ends with a plan

which is not required for the assignments in this course.

Abdominal Assessment Case Study Episodic Note Transcript

Subjective: Chief Compliant/Concern: "My stomach hurts, I have diarrhea & nothing

seems to help." • History of Present Illness: JR, a 47-year-old white male complains of having

generalized abdominal pain that started three days ago. He has not taken any medications

because he did not know what to take. He states the pain is a 5/10 today but has been as much

as 9/10 when it first started. He has been able to eat, with some nausea afterward. • Patient

Medical History: HTN, Diabetes, history of GI bleed four years ago • Medications: Lisinopril

10mg, Amlodipine 5 mg, Metformin 1000mg, Lantus 10 units q hs • Allergies: NKDA • Family

History: No history of colon cancer, Patient's father history DMT2, HTN and Patient's Mother

history HTN, Hyperlipidemia, GERD. Social History: Denies tobacco use; occasional alcohol

use, married, three children (one girl, two boys)

Objective: Vital Signs: Temp 99.8; BP 160/86, RR 16, P 92; HT 5'10; WT 248 lbs. Heart

RRR, no murmurs. Lungs: CTA, chest wall, symmetrical. Skin: Intact without lesions, no

urticaria. Abdomen: Soft, hyperactive bowel sounds, really intense pain in the LLQ.

The diagnostic assessments are left lower quadrant pain and gastroenteritis. The plan

section is not required for the assignments in this course (NURS 6512) but will be required for

future courses.
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