NURS 6512 Lab Assignment: Assessing the Abdomen Essay

NURS 6512 Lab Assignment: Assessing the Abdomen Essay

NURS 6512 Lab Assignment: Assessing the Abdomen Essay

 Lab Assignment: Assessing the Abdomen

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In the given case study, a white man 47-year-old J.R. presents with a chief complaint of experiencing diffuse abdominal pain, which commenced three days before seeking medical attention. The patient refrained from taking any medications due to a lack of knowledge regarding appropriate courses of treatment. The patient reports that the level of pain experienced today is rated at 5 out of 10, whereas during the initial onset, it reached a maximum intensity of 9 out of 10. He has successfully consumed food, albeit experiencing mild nausea subsequently. This paper aims to show how to assess the provided subjective and objective evidence to establish the patient’s main and differential diagnosis.

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Subjective Data

 The patient’s major symptoms of nausea, stomach discomfort, and diarrhea are primarily highlighted by the subjective information given. It is necessary to provide further details, starting with the location and whether or not the abdomen discomfort has been growing worse or better. Additionally, the patient must provide additional details about the kind of pain they are experiencing, such as whether it is dull or throbbing. For a fuller assessment of the patient, further details on the time and frequency of the patient’s nausea and diarrhea are also required. The patient also states that he has diarrhea, but he does not go into more detail about the nature of her bowel movements or the qualities of the stool, which are essential for excluding differential diagnoses (Ball et al., 2019). Additional information is needed on the frequency, dose, and duration of usage of the particular medications specified in the patient’s current medication. The knowledge will aid in promoting good prescribing practices and preventing negative medication responses. Other pertinent information, such as healthy diet and exercise habits, is absent from the offered subjective information.

Objective Data

  The objective data is rather accurate, but there is not much there to help with the patient’s primary complaint’s further examination. Adult patients with comorbidities must get a thorough physical examination from head to toe to be sure there are no underlying conditions that might be causing the current symptoms. After doing a physical examination, the doctor was able to determine that the patient’s discomfort, which was accompanied by hyperactive bowel noises, was coming from the left lower abdominal quadrant. Further examination of the patient’s abdomen is necessary to build on these findings to look for bulges, hernias, swollen veins, or tumors (Black et al., 2020). To determine if the patient’s history of GI bleeding has been fully resolved, visual examinations are also required. Additionally, the objective data lacks nutritional evaluation results, which are essential for excluding dietary explanations of the patient’s symptoms like food poisoning.

Assessment

  Gastroenteritis is suspected based on the patient assessment that has been presented. Although not definitively, the assessment is supported by both the presented subjective and objective data. The symptoms of gastroenteritis include GI disturbances including diarrhea, nausea, vomiting, and stomach discomfort for which the patient tests positive. Missing are several crucial diagnostic indicators including dysuria and infection symptoms (Ball et al., 2019). As a result, the objective data show that individuals with gastroenteritis also had stomach aches in the left lower quadrant and excessive bowel sounds (Wilson et al., 2019). However, a stool investigation was necessary for culture and sensitivity tests to accurately identify the pathogenic organisms to validate this diagnosis.

Appropriate Diagnostic Tests

Patients who exhibit gastrointestinal symptoms such as diarrhea, abdominal pain, and nausea, which are frequently observed in various gastrointestinal disorders, necessitate a thorough evaluation of the abdominal region to facilitate precise diagnosis. To begin, it is imperative to conduct blood tests, such as a complete blood count, to eliminate the possibility of infections. In the context of the presented case study, it was imperative to perform a prompt stool examination to ascertain the specific etiological agent responsible for the patient’s condition, such as rotavirus or other bacterial pathogens known to induce gastroenteritis (Black et al., 2020). Metabolic panel tests are essential for assessing the adequacy of diabetes management and devising strategies to address the patient’s overweight condition. To exclude potential malformations or abnormalities that may be contributing to the patient’s symptoms, it is imperative to conduct comprehensive imaging examinations, such as CT scans and X-rays, encompassing the entirety of the abdominal region. To diagnose calicivirus infection in the stool, it is necessary to include additional tests such as Polymerase Chain Reaction (PCR).

Current Diagnosis

 A gastroenteritis diagnosis was made for the patient in the case study that was supplied. Since the lab data lack information on the etiological bacteria, they cannot completely support this diagnosis. The diagnosis cannot be accepted at this time since it can only be verified by the results of the stool test. As a consequence, the patient’s tests for signs of infection, such as fever and chills, which are necessary for diagnosing gastroenteritis in patients, came back negative. The patient revealed that they have experienced gastrointestinal bleeding in the past, which is a key contributing cause to their current problems (Sunkara et al., 2019). Additional investigation into the patient’s GI bleeding source and to see if it has anything to do with the current symptoms was necessary to rule out other possible causes such as intestinal obstruction, irritable bowel syndrome (IBS), and inflammatory bowel disease.

Differential Diagnosis

The three primary differential diagnoses encompass inflammatory bowel disease (IBD), irritable bowel syndrome (IBS), and intestinal obstruction (IO). IBD is a broad term used to describe a group of disorders that exhibit persistent inflammation in the GI tract (Gatt et al., 2019). The two primary forms of IBD encompass ulcerative colitis and Crohn’s disease. Individuals afflicted with this disorder will exhibit symptoms such as diminished appetite, hematochezia, hematuria, fatigue, abdominal discomfort, and diarrhea. The individual exhibits symptoms of abdominal discomfort and diarrhea. However, it is necessary to conduct a stool test to confirm this diagnosis.

Irritable bowel syndrome (IBS) is a prevalent condition that impacts the functioning of the large intestines. According to Fairbrass et al. (2020), individuals who have been diagnosed with IBS commonly exhibit symptoms such as diarrhea, pain in the abdomen, cramping, bloating, and constipation. The patient exhibits a majority of these symptoms, thereby indicating the potential diagnosis of IBS. Nevertheless, it is imperative to conduct upper endoscopy and colonoscopy procedures to validate this diagnosis.

Intestinal obstruction (IO) is a notable physiological impediment of the gastrointestinal tract caused by a pathological state resulting in the obstruction of bowel transit (Sabzghabaei et al., 2022). The clinical manifestations of this disorder encompass cramping, abdominal pain, absence of flatus, and obstipation. However, a colon X-ray is required to validate this diagnosis.

Conclusion

A thorough examination of the abdomen region is necessary for patients who arrive with GI symptoms such as diarrhea, abdominal discomfort, and nausea, which are typical for many GI illnesses. This will help with an appropriate diagnosis. Gastroenteritis is most likely the patient’s main condition. The diagnosis cannot be accepted at this time since it can only be verified by the results of the stool test. The differential diagnoses of IBD, IBS, and IO are also possible.

 References

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. ISBN: 9780323545389

Black, C. J., Drossman, D. A., Talley, N. J., Ruddy, J., & Ford, A. C. (2020). Functional gastrointestinal disorders: advances in understanding and management. The Lancet, 396(10263), 1664–1674. https://doi.org/10.1016/s0140-6736(20)32115-2‌

Fairbrass, K. M., Costantino, S. J., Gracie, D. J., & Ford, A. C. (2020). Prevalence of irritable bowel syndrome-type symptoms in patients with inflammatory bowel disease in remission: a systematic review and meta-analysis. The Lancet Gastroenterology & Hepatology, 5(12), 1053-1062. https://doi.org/10.1016/S2468-1253(20)30300-9

Gatt, K., Schembri, J., Katsanos, K. H., Christodoulou, D., Karmiris, K., Kopylov, U., … & Ellul, P. (2019). Inflammatory bowel disease [IBD] and physical activity: a study on the impact of the diagnosis on the level of exercise amongst patients with IBD. Journal of Crohn’s and Colitis, 13(6), 686-692. https://doi.org/10.1093/ecco-jcc/jjy214

Sabzghabaei, A., Shojaei, M., & Chavoshzadeh, M. (2022). Diagnostic Accuracy of Ultrasonography by Emergency Medicine Resident in Detecting Intestinal Obstruction; a Pilot Study. Archives of Academic Emergency Medicine, 10(1), e50-e50. https://doi.org/10.22037/aaem.v10i1.1628

Sunkara, T., Rawla, P., Yarlagadda, K. S., & Gaduputi, V. (2019). Eosinophilic gastroenteritis: diagnosis and clinical perspectives. Clinical and experimental gastroenterology, 12, 239. DOI: 10.2147/CEG.S173130.

Wilson, B., Rossi, M., Dimidi, E., & Whelan, K. (2019). Prebiotics in irritable bowel syndrome and other functional bowel disorders in adults: a systematic review and meta-analysis of randomized controlled trials. The American Journal of Clinical Nutrition, 109(4), 1098–1111. https://doi.org/10.1093/ajcn/nqy376

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LAB ASSIGNMENT: ASSESSING THE ABDOMEN

A male went to the emergency room for severe midepigastric abdominal pain. He was diagnosed with AAA ; however, as a precaution, the doctor ordered a CTA scan.

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

RESOURCES

Be sure to review the Learning Resources before completing this activity.

Click the weekly resources link to access the resources.

WEEKLY RESOURCES

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 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 Download 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”Download 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”Download 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”Download 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 115, “X-Ray Interpretation of Abdomen” Download “X-Ray Interpretation of Abdomen”(pp. 514–520)

Note: Download this Student Checklist and Abdomen Key Points to use during your practice abdominal examination.

Document: Midterm Exam Review Download Midterm Exam Review(Word document)

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/Links to an external site.

Optional Resources

LeBlond, R. F., Brown, D. D., & DeGowin, R. L. (2020). DeGowin’s diagnostic examination (11th ed.). New York, NY: McGraw Hill Medical.

Chapter 9, “The Abdomen, Perineum, Anus, and Rectosigmoid”

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”

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.

Chabok, A., Thorisson, A., Nikberg, M., Schultz, J. K., & Sallinen, V. (2021). Changing paradigms in the management of acute uncomplicated diverticulitisLinks to an external site.. Scandinavian Journal of Surgery, 110(2), 180–186. https://doi.org/10.1177/14574969211011032

Hussein, A., Arena, A., Yu, C., Cirilli, A., & Kurkowski, E. (2021). Abdominal pain in the elderly patient: Point-of-care ultrasound diagnosis of small bowel obstructionLinks to an external site.. Clinical Practice and Cases in Emergency Medicine, 5(1), 127–128. https://doi.org/10.5811/cpcem.2020.11.50029

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 INFORMATION

Before submitting your final assignment, you can check your draft for authenticity. To check your draft, access the Turnitin Drafts from the Start Here area.

To submit your completed assignment, save your Assignment as WK6Assgn1+last name+first initial.

Then, click on Start Assignment near the top of the page.

Next, click on Upload File and select Submit Assignment for review.

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Rubric

NURS_6512_Week_6_Assignment_1_Rubric

NURS_6512_Week_6_Assignment_1_Rubric
Criteria Ratings Pts
This criterion is linked to a Learning OutcomeWith regard to the SOAP note case study provided, address the following:Analyze the subjective portion of the note. List additional information that should be included in the documentation.
12 to >9.0 ptsExcellent

The response clearly, accurately, and thoroughly analyzes the subjective portion of the SOAP note and lists detailed additional information to be included in the documentation.

9 to >6.0 ptsGood

The response accurately analyzes the subjective portion of the SOAP note and lists additional information to be included in the documentation.

6 to >3.0 ptsFair

The response vaguely and/or with some inaccuracy analyzes the subjective portion of the SOAP note and vaguely and/or with some inaccuracy lists additional information to be included in the documentation.

3 to >0 ptsPoor

The response inaccurately analyzes or is missing analysis of the subjective portion of the SOAP note, with inaccurate and/or missing additional information included in the documentation.

12 pts
This criterion is linked to a Learning OutcomeAnalyze the objective portion of the note. List additional information that should be included in the documentation.
12 to >9.0 ptsExcellent

The response clearly, accurately, and thoroughly analyzes the objective portion of the SOAP note and lists detailed additional information to be included in the documentation.

9 to >6.0 ptsGood

The response accurately analyzes the objective portion of the SOAP note and lists additional information to be included in the documentation.

6 to >3.0 ptsFair

The response vaguely and/or with some inaccuracy analyzes the objective portion of the SOAP note and vaguely and/or inaccurately lists additional information to be included in the documentation.

3 to >0 ptsPoor

The response inaccurately analyzes or is missing analysis of the objective portion of the SOAP note, with inaccurate and/or missing additional information included in the documentation.

12 pts
This criterion is linked to a Learning OutcomeIs the assessment supported by the subjective and objective information? Why or why not?
16 to >13.0 ptsExcellent

The response clearly and accurately identifies whether or not the assessment is supported by the subjective and/or objective information, with a thorough and detailed explanation.

13 to >10.0 ptsGood

The response accurately identifies whether or not the assessment is supported by the subjective and/or objective information, with an explanation.

10 to >7.0 ptsFair

The response vaguely and/or inaccurately identifies whether or not the assessment is supported by the subjective and/or objective information, with a vague explanation.

7 to >0 ptsPoor

The response inaccurately identifies whether or not the assessment is supported by the subjective and/or objective information, with an inaccurate or missing explanation.

16 pts
This criterion is linked to a Learning OutcomeWhat diagnostic tests would be appropriate for this case, and how would the results be used to make a diagnosis?
20 to >17.0 ptsExcellent

The response thoroughly and accurately describes appropriate diagnostic tests for the case and explains clearly, thoroughly, and accurately how the test results would be used to make a diagnosis.

17 to >14.0 ptsGood

The response accurately describes appropriate diagnostic tests for the case and explains clearly and accurately how the test results would be used to make a diagnosis.

14 to >11.0 ptsFair

The response vaguely and/or with some inaccuracy describes appropriate diagnostic tests for the case and vaguely and/or with some inaccuracy explains how the test results would be used to make a diagnosis.

11 to >0 ptsPoor

The response inaccurately describes appropriate diagnostic tests for the case, with an inaccurate or missing explanation of how the test results would be used to make a diagnosis.

20 pts
This criterion is linked to a Learning Outcome·   Would you reject or accept the current diagnosis? Why or why not?·   Identify three possible conditions that may be considered as a differenial diagnosis for this patient. Explain your reasoning using at least three different references from current evidence-based literature.
25 to >22.0 ptsExcellent

The response states clearly whether to accept or reject the current diagnosis, with a thorough, accurate, and detailed explanation of sound reasoning. The response clearly, thoroughly, and accurately identifies three conditions as a differential diagnosis, with reasoning that is explained clearly, accurately, and thoroughly using at least three different references from current evidence-based literature.

22 to >19.0 ptsGood

The response states whether to accept or reject the current diagnosis, with an accurate explanation of sound reasoning. The response accurately identifies three conditions as a differential diagnosis, with reasoning that is explained accurately using three different references from current evidence-based literature.

19 to >16.0 ptsFair

The response states whether to accept or reject the current diagnosis, with a vague explanation of the reasoning. The response identifies two or three conditions as a differential diagnosis, with reasoning that is explained vaguely and/or inaccurately using three references from current evidence-based literature.

16 to >0 ptsPoor

The response inaccurately or is missing a statement of whether to accept or reject the current diagnosis, with an explanation that is inaccurate and/or missing. The response identifies two or fewer conditions as a differential diagnosis, with reasoning that is missing or explained inaccurately using three or fewer references from current evidence-based literature.

25 pts
This criterion is linked to a Learning OutcomeWritten Expression and Formatting – Paragraph Development and Organization: Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused–neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria.
5 to >4.0 ptsExcellent

Paragraphs and sentences follow writing standards for flow, continuity, and clarity. A clear and comprehensive purpose statement, introduction, and conclusion are provided that delineate all required criteria.

4 to >3.0 ptsGood

Paragraphs and sentences follow writing standards for flow, continuity, and clarity 80% of the time. Purpose, introduction, and conclusion of the assignment are stated, yet are brief and not descriptive.

3 to >2.0 ptsFair

Paragraphs and sentences follow writing standards for flow, continuity, and clarity 60%–79% of the time. Purpose, introduction, and conclusion of the assignment are vague or off topic.

2 to >0 ptsPoor

Paragraphs and sentences follow writing standards for flow, continuity, and clarity < 60% of the time. No purpose statement, introduction, or conclusion were provided.

5 pts
This criterion is linked to a Learning OutcomeWritten Expression and Formatting – English writing standards: Correct grammar, mechanics, and proper punctuation
5 to >4.0 ptsExcellent

Uses correct grammar, spelling, and punctuation with no errors.

4 to >3.0 ptsGood

Contains a few (1 or 2) grammar, spelling, and punctuation errors.

3 to >2.0 ptsFair

Contains several (3 or 4) grammar, spelling, and punctuation errors.

2 to >0 ptsPoor

Contains many (≥ 5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding.

5 pts
This criterion is linked to a Learning OutcomeWritten Expression and Formatting – The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, running heads, parenthetical/in-text citations, and reference list.
5 to >4.0 ptsExcellent

Uses correct APA format with no errors.

4 to >3.0 ptsGood

Contains a few (1 or 2) APA format errors.

3 to >2.0 ptsFair

Contains several (3 or 4) APA format errors.

2 to >0 ptsPoor

Contains many (≥ 5) APA format errors.

5 pts
Total Points: 100

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