NURS 6512 Assignment 2 Assessment of the Abdomen and Gastrointestinal System 

Sample Answer for NURS 6512 Assignment 2 Assessment of the Abdomen and Gastrointestinal System  Included After Question

NURS 6512 Assignment 2 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. 

NURS 6512 Assignment 2 Assessment of the Abdomen and Gastrointestinal System 
NURS 6512 Assignment 2 Assessment of 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 
  • Analyze chest X-Ray and abdominal X-Ray imaging 
  • Identify concepts, theories, and principles related to advanced health assessment 

 

Learning Resources 

 

Required Readings (click to expand/reduce)  

 

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 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. 

 

 

Chabok, A., Thorisson, A., Nikberg, M., Schultz, J. K., & Sallinen, V. (2021). Changing paradigms in the management of acute uncomplicated diverticulitis. 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 obstruction. Clinical Practice and Cases in Emergency Medicine, 5(1), 127–128. https://doi.org/10.5811/cpcem.2020.11.50029 

 

 

Document: Midterm Exam Review (Word document) 

 

Optional Resource 

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. 

 

Required Media (click to expand/reduce)  

 

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 

 

Photo Credit: Getty Images/Hero Images 

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 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 

  1. Analyze the subjective portion of the note. List additional information that should be included in the documentation. 
  1. Analyze the objective portion of the note. List additional information that should be included in the documentation. 
  1. Is the assessment supported by the subjective and objective information? Why or why not? 
  1. What diagnostic tests would be appropriate for this case, and how would the results be used to make a diagnosis? 
  1. 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: 

Week 6 Assignment 1 

 

 

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? 

 

Photo Credit: [BrianAJackson]/[iStock / Getty Images Plus]/Getty Images 

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

Week 7 Required Media  

 

Photo Credit: [fergregory]/[iStock / Getty Images Plus]/Getty Images 

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 

A Sample Answer For the Assignment: NURS 6512 Assignment 2 Assessment of the Abdomen and Gastrointestinal System 

Title: NURS 6512 Assignment 2 Assessment of the Abdomen and Gastrointestinal System 

NURS 6512: Assessment of Abdomen and Gastrointestinal System Episodic/Focused SOAP Note

NURS 6512: Advanced Health Assessment and Diagnostic Reasoning

Week Seven: Assessment of Abdomen and Gastrointestinal System

Review of case study #2

Scenario: A 50-year-old male complains of burning pain starting at the abdomen and rising to the middle of his chest. He describes the pain as a gnawing feeling that begins after meals, especially when lying down.

Episodic/Focused SOAP Note for Throat Exam

Patient Information: V.S.     Age: 50 y.o.        Sex: Male          DOB: 8/7/1967

S.

Chief Complaint/Reason for Visit:

The patient reported abdominal discomfort for the past two days that feels like “burning sensation in his chest.”

History of Present Illness:

Mr. V.S. is a 50 y/o Caucasian male with h/o hyperlipidemia, hypothyroidism, hypertension, DM Type II, presenting with c/o abdominal discomfort ranging from 5 to 6 out of 10 for two days. According to the patient, his stomach discomfort has however been ongoing for the past two days and describes it as burning pain starting at the mid-abdomen and rising to the middle of his chest. He reported that the pain usually begins when he eats and worsens when lying down but subsides when he walks. Patient denies constipation or diarrhea. His last meal was at 14:00 today. According to the patient, he recently started taking aspirin once a day as advised by his primary care physician. NURS 6512: Assessment of Abdomen and Gastrointestinal System Episodic/Focused SOAP Note

Current Medications:

Atorvastatin (Lipitor) 40 mg tablet Take 40 mg nightly

Levothyroxine (SYNTHROID) 100 mcg once daily

Metformin (GLUCOPHAGE) 500 mg tablet two times daily (with breakfast & dinner)

Aspirin 81mg once daily

Allergies: No known allergies

PMHx:

  • Diabetes mellitus (managed by diet and medication)
  • Diabetes type 2, controlled with diet and medication
  • Hyperlipidemia (currently on medication)
  • Hypothyroidism (managed by medication)

Fam Hx: Reported both parents are alive, father with hypertension, mother with diabetes.

Personal/Social History: Drinks ETOH occasionally. Consumes 2-3 cans of beer two times per week. Denies smoking, and illicit drug use.

Review of Systems:

Constitutional:  A&O x4, pleasant and cooperative. Reports abdominal pain 5-6/10. No acute distress. Denies weight loss, weakness, or fatigue.

HEENT:  Denies headache, sore throat or changes in hearing.

SKIN:  No rash or itching.

CARDIOVASCULAR:  Reported burning sensation on his chest when lying down.

RESPIRATORY:  Denies shortness of breath or cough.

GASTROINTESTINAL:  Reported abdominal discomfort for the past two days ranging from 5-6/10. Described as “gnawing” and “burning.” Denies nausea or vomiting. No change in bowel pattern.

GENITOURINARY:  Denies dysuria or hematuria.

NEUROLOGICAL:  Denies focal loss of strength or loss of sensation.

MUSCULOSKELETAL:  Denies focal weakness, facial droop, or joint swelling.

HEMATOLOGIC:  No anemia, bleeding or bruising. NURS 6512: Assessment of Abdomen and Gastrointestinal System Episodic/Focused SOAP Note

LYMPHATICS:  No enlarged nodes. No cervical lymphadenopathy

ALL OTHER SYSTEMS REVIEWED AND NEGATIVE OF PERTINENT FINDINGS

O.

Physical exam: Vital signs: B/P 117/59, Pulse 108 (strong and regular); Temp 98.3F orally; RR 18; non-labored; SpO2: 96% room air;

Height 1.575 m (5′ 2″), weight 73.5 kg (162 lb),

General: A&O x4, pleasant and cooperative. Not in any acute distress.

HEENT: Normocephalic and atraumatic. Sclera anicteric, No conjunctival erythema, PERRLA, oropharynx red, moist mucous membranes.

Neck: Supple. No JVD. Trachea midline. No pain, swelling or palpable nodules.

Chest/Lungs: Clear to auscultation bilaterally. No wheezing, crackles or rhonchi. No accessory muscle use.

Heart/Peripheral Vascular: Regular rate and rhythm noted. No murmurs. No palpitation. No peripheral edema to palpation bilaterally.  NURS 6512: Assessment of Abdomen and Gastrointestinal System Episodic/Focused SOAP Note

ABD: Reports of 5-6/10 pain. Soft, nontender, nondistended. Hyperactive BS. No palpable hepatosplenomegaly

Genital/Rectal: continent of bladder and bowel.

Musculoskeletal: Normal range of motion. Regular muscle mass for age. No swelling or joint deformities.

Neuro: Alert and oriented x4. Strength and sensation intact.

Skin/Lymph Nodes: No cervical lymphadenopathy. No rashes, or erythema. No lesions. NURS 6512: Assessment of Abdomen and Gastrointestinal System Episodic/Focused SOAP Note

Diagnostic results:

EKG: NSR

Laboratory studies:

CBC – WBC 9.4; H/H: 14.3/41.0; PLT: 289.

Chemistry Panel: BUN/Crea: 19/0.52; Glucose: 117*

  1. Pylori serology: negative

Esophageal pH Test: pending

NURS 6512: Assessment of Abdomen and Gastrointestinal System Episodic/Focused SOAP Note

 

A.

Differential Diagnoses (DD):

  • Gastroesophageal Reflux Disease (GERD): backward flow of gastric contents, which are typically acidic, into the esophagus (Ball, Dains, Flynn, Solomon, & Stewart, 2015, p. 400).

–    Patient with reports of burning, gnawing pain in the mid-epigastrium that worsens with recumbency (Baumann, Dains, & Scheibel, 2016, p. 27).

–    Risk factors for GERD include obesity, pregnancy, smoking, eating large meals or eating late at night, eating certain foods (triggers) such as fatty or fried foods, drinking certain beverages such as alcohol or coffee, taking certain medications, such as aspirin (Mayo Foundation for Medical Education and Research, 2017).

–    Due to the reported symptoms, alcohol consumption, and recent changes in the patient’s medication, GERD is the primary diagnosis for the patient. NURS 6512: Assessment of Abdomen and Gastrointestinal System Episodic/Focused SOAP Note

  • Acute coronary syndrome: may have heartburn or a bitter taste in the mouth due to stomach fluid “coming up” which usually occurs after eating and gastroesophageal reflux disease (GERD) is the most common cause of non-cardiac chest pain (The Cleveland Clinic Foundation, 2015).
  • Peptic Ulcer: associated with reports of burning or gnawing pain that occurs most often with an empty stomach, stress, and alcohol intake which is relieved with food intake (Baumann, Dains, & Scheibel, 2016, p. 27).
  • Achalasia: a condition where the esophagus is unable to move food into the stomach as the lower esophageal sphincter stays closed during swallowing, back up of food results and symptoms include vomiting undigested food, chest pain, heartburn and weight loss (The Cleveland Clinic Foundation, 2017).
  • Gastritis: is a constant burning pain in the epigastric area that can be accompanied by nausea, vomiting, diarrhea, or fever and alcohol, nonsteroidal inflammatory drugs and salicylates make the pain worse (Baumann, Dains, & Scheibel, 2016, p. 27).
  • Hiatal Hernia with esophagitis: is a condition where part of the stomach passes through the esophageal hiatus in the diaphragm and into the chest cavity with symptoms of epigastric pain or heartburn that worsens with lying down and is resolved by sitting up or antacids (Ball, Dains, Flynn, Solomon, & Stewart, 2015, p. 401).

 

References

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015). Seidel’s guide to physical examination (8th ed.). St. Louis, MO: Elsevier Mosby.

Baumann, L. C., Dains, J. E., & Scheibel, P. (2016). Advanced health assessment and clinical diagnosis in primary care (5th ed.). St. Louis, MO: Elsevier Mosby. NURS 6512: Assessment of Abdomen and Gastrointestinal System Episodic/Focused SOAP Note

Mayo Foundation for Medical Education and Research. (2017, November). Gastroesophageal reflux disease (GERD). Retrieved from https://www.mayoclinic.org/diseases-conditions/gerd/symptoms-causes/syc-20361940

The Cleveland Clinic Foundation. (2015, June). Non-Cardiac Chest Pain: GERD. Retrieved from https://my.clevelandclinic.org/health/diseases/15851-gerd-non-cardiac-chest-pain

The Cleveland Clinic Foundation. (2017, July). Swallowing Problems: Achalasia. Retrieved from https://my.clevelandclinic.org/health/diseases/17534-swallowing-problems-achalasia/symptoms–diagnosis?view=print NURS 6512: Assessment of Abdomen and Gastrointestinal System Episodic/Focused SOAP Note