NURS 6512 Assessing the Abdomen Lab Assignment Example
NURS 6512 Assessing the Abdomen Lab Assignment
NURS 6512 Assessing the Abdomen Lab Assignment Brief
Course: NURS 6512 – Advanced Health Assessment and Diagnostic Reasoning
Assignment Title: NURS 6512 – Assignment 1: Lab Assignment: Assessing the Abdomen
Assignment Instructions Overview
In this lab assignment, you will analyze an episodic note case study describing abnormal findings in patients presenting with abdominal symptoms. Your task is to thoroughly assess the provided patient scenario, identifying essential history elements, performing appropriate physical examinations, and recommending diagnostic tests to aid in formulating a differential diagnosis.
Understanding Assignment Objectives
This assignment aims to evaluate your ability to:
- Analyze subjective and objective data in an episodic note.
- Apply concepts from advanced health assessment to assess abdominal and gastrointestinal conditions.
- Formulate a differential diagnosis based on clinical findings and evidence-based literature.
The Student’s Role
As a student, your role is to:
- Review the provided episodic note case study and associated learning resources.
- Determine relevant patient history details crucial for accurate assessment.
- Recommend appropriate physical exams and diagnostic tests based on the patient’s clinical presentation.
- Formulate a differential diagnosis considering potential conditions aligned with the patient’s symptoms and clinical data.
Competencies Measured
This assignment assesses the following competencies:
- Ability to collect comprehensive patient history related to abdominal and gastrointestinal symptoms.
- Proficiency in conducting systematic physical examinations to assess abdominal findings.
- Skill in recommending evidence-based diagnostic tests to aid in accurate diagnosis.
- Capacity to critically evaluate and justify differential diagnosis based on clinical evidence.
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NURS 6512 Assessing the Abdomen Lab Assignment Example
NURS 6512 – Assignment 1: Lab Assignment: Assessing the Abdomen
SOAP Note
S:
CC: “My stomach hurts, I have diarrhea, and nothing seems to help.”
HPI: M.N, a 47-year-old woman, presents with an abdominal pain complaint that began three days ago. She hasn’t taken any medicines since she didn’t know what to take. She states her pain rate is 5/10 better than it first began.
PMH: Hypertension, Diabetes, GI bleeding history four years back.
Medications: Amlodipine 5 mg, Lisinopril 10mg, and Metformin 1000mg.
Allergies: NKDA
Family History: No history of colon cancer, Father has DMT2, Hypertension, Mother as well has HTN, Hyperlipidemia, and GERD
Social: Doesn’t smoke, married with three kids (2 girls and a boy)
O:
Vital signs: Temp 99.8; RR 16; P 92; BP 160/86; Height 5’10”; Weight 248lbs
Heart: No murmurs
Lungs: Clear chest walls
Skin: Intact without urticaria and lesions
Abdomen: hyperactive bowel sounds, soft
Assessment:
Gastroenteritis
Subjective Portion Analysis
The subjective portion of the SOAP note details the patient’s symptoms and history. It is crucial for understanding the patient’s current condition and guiding further examination and treatment. The covered areas include chief complaints, history of present illness, past medical history, current medications, social history, allergies, and family history. However, additional information should be gathered to complete the history, such as the patient’s location and recent dietary intake which could contribute to symptoms (Colyar, 2015).
Objective Portion Analysis
The objective part of the SOAP note provides the physician’s findings from the physical examination. While it includes vital signs, cardiovascular, respiratory, and abdominal assessments, a more comprehensive head-to-toe examination is necessary. This would encompass evaluation of additional areas like neurological and musculoskeletal systems to rule out other potential causes of symptoms (LeBlond et al., 2014).
Assessment
The assessment is supported by both the subjective and objective data. Subjective data supports the diagnosis through the patient’s reported symptoms and history. Objective findings include abdominal tenderness and hyperactive bowel sounds, aligning with the diagnosis of gastroenteritis (Dains et al., 2019).
Diagnostic Tests
Appropriate diagnostic tests for this case include stool culture to identify infectious agents causing gastroenteritis. Endoscopy or colonoscopy may also be considered to evaluate for other gastrointestinal conditions presenting similarly to gastroenteritis (LeBlond et al., 2014).
Current Diagnosis
The current diagnosis of gastroenteritis is well-supported by the patient’s symptoms and objective findings. Symptoms include abdominal pain, diarrhea, and nausea, which are typical manifestations of gastroenteritis. The absence of severe complications and improvement without treatment further supports this diagnosis (Bányai et al., 2018).
Differential Diagnosis
- Amebiasis: Parasitic infection causing symptoms similar to gastroenteritis, including diarrhea and abdominal pain (Bányai et al., 2018).
- Bacterial gastroenteritis: Infection of the gut by bacterial pathogens presenting with severe abdominal cramps and diarrhea (Barrett & Fhogartaigh, 2017).
- Food poisoning: Toxin-mediated illness from contaminated food, leading to gastrointestinal symptoms like vomiting and diarrhea (Barrett & Fhogartaigh, 2017).
References
Bányai, K., Estes, M. K., Martella, V., & Parashar, U. D. (2018). Viral gastroenteritis. The Lancet, 392(10142), 175-186. Retrieved from https://www.sciencedirect.com/science/article/abs/pii/S0140673618311280
Barrett, J., & Fhogartaigh, C. N. (2017). Bacterial gastroenteritis. Medicine, 45(11), 683-689. Retrieved from https://www.sciencedirect.com/science/article/abs/pii/S1357303917302177
Colyar, M. R. (2015). Advanced practice nursing procedures. Philadelphia, PA: F. A. Davis.
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.
LeBlond, R. F., Brown, D. D., & DeGowin, R. L. (2014). DeGowin’s diagnostic examination (10th ed.). New York, NY: McGraw Hill Medical.
Detailed Assessment Instructions for the NURS 6512 Assessing the Abdomen Lab Assignment
Week 6: Assessment of the Abdomen and Gastrointestinal System
On your way home from dinner, you start experiencing sharp pains in your abdomen. You ate seafood—could you have food poisoning? What else might be causing your pain? Appendicitis? Should you head to the emergency room, or should you wait and see how you feel in the morning?
Numerous ailments can affect the GI system and the abdomen. Because the organs are so close, it can be difficult to conduct an accurate assessment. Also, pain in another area of the body can affect the GI system. For example, patients with chronic migraines often report nausea.
This week, you will explore how to assess the abdomen and gastrointestinal system.
Learning Objectives
Students will:
- Evaluate abnormal abdomen and gastrointestinal findings
- Apply concepts, theories, and principles relating to health assessment techniques and diagnoses for the abdomen and gastrointestinal system
- Identify concepts, theories, and principles related to advanced health assessment
Learning Resources
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. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the Copyright Clearance Center.
Document: Midterm Exam Review (Word document)
Optional Resource
LeBlond, R. F., Brown, D. D., & DeGowin, R. L. (2014). DeGowin’s diagnostic examination (10th ed.). New York, NY: McGraw Hill Medical.
- Chapter 9, “The Abdomen, Perineum, Anus, and Rectosigmoid” (pp. 445–527)
This chapter explores the health assessment processes for the abdomen, perineum, anus, and rectosigmoid. This chapter also examines the symptoms of many conditions in these areas.
- Chapter 10, “The Urinary System” (pp. 528–540)
In this chapter, the authors provide an overview of the physiology of the urinary system. The chapter also lists symptoms and conditions of the urinary system.
Required Media
Assessment of the Abdomen and Gastrointestinal System – Week 6 (14m)
Online media for Seidel’s Guide to Physical Examination
It is highly recommended that you access and view the resources included with the course text, Seidel’s Guide to Physical Examination. Focus on the videos and animations in Chapter 17 that relate to the assessment of the abdomen and gastrointestinal system. Refer to Week 4 for access instructions on https://evolve.elsevier.com/
Assignment 1: Lab Assignment: Assessing the Abdomen
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:
- Review this week’s Learning Resources, and consider the insights they provide about the case study.
- Consider what history would be necessary to collect from the patient in the case study.
- 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?
- Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.
The Assignment
- Analyze the subjective portion of the note. List additional information that should be included in the documentation.
- Analyze the objective portion of the note. List additional information that should be included in the documentation.
- Is the assessment supported by the subjective and objective information? Why or why not?
- What diagnostic tests would be appropriate for this case, and how would the results be used to make a diagnosis?
- 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.
By Day 7 of Week 6
Submit your Lab Assignment.
Submission and Grading Information
To submit your completed Assignment for review and grading, do the following:
- Please save your Assignment using the naming convention “WK6Assgn1+last name+first initial. (extension)” as the name.
- Click the Week 6 Assignment 1 Rubric to review the Grading Criteria for the Assignment.
- Click the Week 6 Assignment 1 link. You will also be able to “View Rubric” for grading criteria from this area.
- Next, from the Attach File area, click on the Browse My Computer button. Find the document you saved as “WK6Assgn1+last name+first initial. (extension)” and click Open.
- If applicable: From the Plagiarism Tools area, click the checkbox for I agree to submit my paper(s) to the Global Reference Database.
- Click on the Submit button to complete your submission.
Grading Criteria
To access your rubric:
Week 6 Assignment 1 Rubric
Check Your Assignment Draft for Authenticity
To check your Assignment draft for authenticity:
Submit your Week 6 Assignment 1 draft and review the originality report.
Submit Your Assignment by Day 7 of Week 6
To participate in this Assignment:
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