Walden - NURS 6512 Week 6 Assignment - Assignment 1: Lab Assignment: Assessing the Abdomen

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.

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.
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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:

Week 6 Assignment 1

Week 6 Assignment Sample Paper

NURS 6512 – Assignment 1: Lab Assignment: Assessing the Abdomen

Assessing the Abdomen

Student’s Name:

Institutional Affiliation:

Course:

Instructor’s Name:

Date:

Assessing the Abdomen

SOAP Note

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)

Vital signs: Temp 99.8; RR 16; P 92; BP 160/86; Height 5’10”; Weight 248lbs

Heart: No hums

Lungs: Regular chest walls

Skin: Intact without urticaria and lesions

Abdomen: hyperactive bowel reverberations, soft,

Assessment:

Gastroenteritis

Subjective Portion Analysis

The emotional part of the SOAP note helps in analyzing how the patient is feeling. It emphasizes on what patient reports. The subjective part must be systematic, covering a patient’s critical details. Several areas in this soap note have been covered, whereas others haven’t. The covered areas involved chief complaints, history of present disease, past medicinal history, current medications, social history, allergies, and history. Although covered areas helped comprehend the patient’s ailment, the doctor must gather additional information in this particular section. The physician would have collected additional information to provide a complete analysis of the history of the present illness, ask the patient where she was when the symptoms started. The doctor should similarly ask the type of foods the patient had consumed just before the onset of symptoms. The subjective section would as well have emphasized her history of injuries (Colyar 2015). Previous injuries like falling or car accidents may be an aim for current symptoms.

Objective Portion Analysis

The objective part of a SOAP note focuses on the physician’s review. The review should be thorough and should entail a head-to-toe assessment. The objective part of the SOAP focused on the patient’s vital signs, lungs, heart, skin, and abdominal review. Additional information that may be added includes the patient’s overall appearance, general appearance aids in identifying how a patient looks relay to illness. The objective part must similarly contain a review from head to toe. Full body review helps determine the primary diagnosis, and in case the diagnosis is causing the symptoms on numerous body regions. The physician must review the head, nose, eyes, mouth, neck, and chest for the SOAP note. The doctor should similarly assess the patient’s respiratory performance, genitourinary symptoms, neurological and musculoskeletal functioning.

Assessment

The assessment was supported by both the subjective and objective data (Dains, Baumann & Scheibel 2019). Subjective data that supported assessment includes M. Ns chief’s complaint, history of present and past illness, family, and social history. Objective data that supported assessment included an abdominal review that revealed results of LLQ pain. However, the objective analysis was not enough for evaluation as it did not have the laboratory tests and full body review.

Diagnostic Tests

Diagnostic tests suitable for the patient include stool culture to determine parasites, viruses, or bacteria. Endoscopy can as well be used to find the diagnosis. Endoscopy encompasses inserting a camera through the throat to the stomach to check problems like ulcers. A colonoscopy may as well be used to determine intestinal injury or tumors. Colonoscopy inserts a camera through the rectum. Lower gastrointestinal tract radiography may similarly be used to determine intestinal obstructions or the rest of stomach conditions (LeBlond, Brown & DeGowin 2014).

Current Diagnosis

The current diagnosis for the patient is gastroenteritis. This is a condition where the stomach is infected, triggering diarrhea symptoms, vomiting and nausea, and abdominal pain (Bányai et al. 2018). Symptoms might last for a couple of days and vanish without treatment after some days. The illness usually occurs as a result of bacterial or viral infection. I agree with the current diagnosis since the patient reports abdominal pain, diarrhea, and nausea, all of which is gastroenteritis. The patient’s symptoms have as well decreased with no treatment.

Differential Diagnosis

Amebiasis

Amebiasis is a parasitic infection of the intestines triggered by protozoan Entamoeba histolytica. Patients may present with signs and symptoms such as diarrhea, cramping, stomach pains, nausea, appetite loss, and fever.

Bacterial gastroenteritis

Bacterial gastroenteritis transpires when the bacteria cause infection in an individual’s gut (Barrett & Fhogartaigh 2017). This causes inflammation in the intestines and stomach. The affected individual may as well experience symptoms such as vomiting, serious stomach cramps, and diarrhea.

Food poisoning

Food poisoning is a disease triggered by eating polluted food. It is not generally severe, and most individuals feel better in a few days with no treatment. Food poisoning symptoms might involve nausea, cramping, vomiting, or diarrhea.

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.

Exam: Week 6 Midterm Exam

This exam is a test of your knowledge in preparation for your certification exam. No outside resources, including books, notes, websites, or any other type of resource, are to be used to complete this exam. You are expected to comply with Walden University’s Code of Conduct.

This exam will be on topics covered in weeks 1, 2, 3, 4, 5, and 6. Prior to starting the exam, you should review all of your materials. This exam is timed with a limit of 2 hours for completion. When time is up, your exam will automatically submit.

By Day 7 of Week 6

Submit your Midterm Exam.

Submission and Grading Information

Submit Your Midterm Exam by Day 7 of Week 6.

To Complete this Exam:

Week 6 Exam

Assignment 2: Lab Assignment DCE

The causes of abdominal pain can be extremely varied due to the sheer number of structures, organs, and functions within the abdomen. If abdominal pain is caused by a life-threatening condition, then swift and accurate assessment is essential.

In preparation for the Comprehensive (Head-to-Toe) Physical Assessment due in Week 9, it is recommended that you practice performing an abdominal examination this week.

Focused Exam: Abdominal Assignment:

Complete the following in Shadow Health:
Abdominal Concept Lab (Required)
Gastrointestinal (Practice)
Focused Exam: Abdominal Pain (Practice)

What’s Coming Up in Week 7?

Next week, you will explore how to assess the heart, lungs, and peripheral vascular system as you complete your Discussion.

Week 7 Required Media

Next week, you will need to view several videos and animations in the Seidel’s Guide to Physical Examination as well as other media, as required, prior to completing your Discussion. There are several videos of various lengths. Please plan ahead to ensure you have time to view these media programs to complete your Discussion on time.

Next Week

To go to the next week:

Week 7

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Walden – NURS 6512 Week 6 Assignment – Assignment 1: Lab Assignment: Assessing the Abdomen