NURS 6512 Lab Assignment: Assessing the Abdomen
NURS 6512 Lab Assignment: Assessing the Abdomen
Assessing the Abdomen
Students Name
Institution
Instructor
Date
Assessing the Abdomen
PI: JR Age: 47 Gender: Male
S/D:
CC: “My stomach hurts, I have diarrhea, and nothing seems to help.”
History of Present Illness (HPI): JR is a 47-year-old Caucasian male who came to the hospital complaining of generalized abdominal pain which began three days before the present visit. He denies having taken any drug claiming that she had no idea of what to take. He claims that the severity of the pain currently is 5/10 but was worse of up to 9/10 for the past two days. She has been able to eat properly with the pain but complains of being nauseated afterward.
Medications: Lisinopril 10mg. Amlodipine 5 mg. Metformin 1g. Linctus 10 units qhs
Allergies: No known drug allergies
PMHx: HTN. Diabetes. She has a history of gastrointestinal bleeding which occurred four years ago
PSHx: No past surgical history
Sexual/Reproductive History: He is heterosexual and has three children, two boys, and one girl
Soc Hx: He is married and has three children, two boys, and one girl. Denies ever using tobacco. Confirms alcohol use occasionally.
Significant Fam Hx: He has three children, two boys, and one girl. No family history of colon cancer. The father had a history of type 2 diabetes mellitus and HTN. The mother has a history of HTN, GERD, and hyperlipidemia
Review of Systems:
General: He has been eating properly without any difficulties, despite nausea that comes afterward. He has no fever or loss of appetite.
HEENT: Denies itchy nose, palate, eyes, or ears. No problems with nose bleeding, hearing, ringing sound on the ears.
Skin: Intact skin with no lesions, itchiness, urticarial, Acne, Blistering, Dry skin, hives, Eczema, Moles, Nodules, skin oozing or skin cancer.
Respiratory: No coughing, shortness of breath or hemoptysis. CTA, the walls of her chest are well symmetrical. No history of asthma.
Cardiovascular/Peripheral Vascular: no heart murmurs, chest pain, accumulation of fluid or edema of the legs. Denies pain on palpitation or irregular heartbeats.
Gastrointestinal: Complains of severe generalized abdominal pain which has lasted for three days. Denies decreased in appetite. Confirms nausea after eating. Has a history of blood in stool, four years ago. Denies constipation, heartburn, hematemesis, or rectal bleeding.
Musculoskeletal: No unsteady gait or deformities. Confirms having a full range of motion and an excellent bilateral strength in all extremities. Denies pain in the joints or fatigue.
Psychiatric: No anxiety, delusion, auditory/visual hallucinations, depressed mood, homicidal disorder, eating disorder, mental or physical abuse, suicidal thoughts or substance abuse.
Neurological: No difficulties in balance, fainting, coordination, or abnormality in gait. Denies loss of strength, or Tingling/Numbness symptoms.
OBJECTIVE DATA:
P/E:
Vital signs: Temp 99.8; RR 16; BP 160/86; P 92; WT 248lbs; HT 5’10”; BMI 35
Pain: reports abdominal pain severity of 5/10 currently but 9/10 in the last two days. General: The patient is alert and well oriented. The patient can communicate clearly with no difficulties in answering all the questions asked. He maintains good hygiene and seems not to be anxious.
HEENT: pupils are equally dilated, round, bilaterally reactive to light with perfect accommodation. The extraocular movement is intact (EOMI). Clear auditory canal with an intact tympanic membrane. The light reflex presents bilaterally — no signs of enlarged tonsils or mouth wounds.
Skin: The skin is clean and moist, with no signs of scaling, itchiness or moles.
Chest: The thorax is perfectly symmetrical; there are no signs of gross rib deformity. The chest shape and expansion are normal.
Lungs: No diminishing breathing sounds noted, no rales or expiratory wheezes, no rhonchi, wet, and productive cough noted.
Heart: The heart sounds are normal. No murmurs. Regular heart rate and rhythm. The heart rate is regular with the presence of S1, S2, and absence of S3 or S4.
Peripheral Vascular: No signs of edema, ulcers, varicose veins or deformities. No signs of pedal edema. 2+ dorsalis pedis pulses bilaterally confirmed.
Abdomen: generalized tenderness, hyperactive bowel sounds in all the four quadrants, severe pain on the LLQ. No signs of distention or hernia.
Musculoskeletal: Very steady gait with no deformities. Exhibits full range of motion in all extremities — no pain on movement of joints.
Neurological: Very alert and oriented in a good position. Tolerates appropriately to the tests performed — perfect tone with no history of neurological disorders.
Diagnostics: None
ASSESSMENT:
Pain in the Left lower quadrant of the abdomen.
Gastroenteritis– a viral or bacterial infection of the stomach and intestines causing irritations and inflammation of GI lining. Presents with symptoms such as watery diarrhea, nausea and vomiting, abdominal cramping and pain, fever, and a headache (Mayumi et al., 2016).
Current Diagnosis
The current diagnosis of gastroenteritis is inappropriate due to lack of enough information based on the provided data. It has been supported by limited objective and subjective data, which makes it unacceptable. The advanced practice nurse needs additional subjective and objective data in addition to proper diagnostic lab test result to make a firm diagnosis to avoid the high chances of misdiagnosis (Jamal et al., 2017). These lab tests will also make it possible to differentiate and rule out the following differential diagnosis:
- Diverticulitis
- Chron’s
- Ulcerative colitis
- Colon cancer
- Gastroenteritis
- Food poisoning
Diagnostic Tests Required
For proper diagnosis, the nurse in charge needs to order tests such as colonoscopy, stool occult test, liver function tests, biopsy, and CT scan when necessary. The stool occult tests will provide information confirming the cause of the GI bleeding. The liver function test, on the other hand, will measure the patient’s levels of alanine transferase, albumin, alkaline phosphate, aspartate aminotransferase, and bilirubin to rule out any injuries or liver infections (Othman et al., 2017). The CT scan will provide a proper visual of the abdomen to determine any injuries to any organ, or abnormal growth or any mass blockage within the abdomen. Lastly, the biopsy will determine the actual disease affecting a particular body tissue.
Differential Diagnosis
- Diverticulitis: this is a chronic inflammatory condition or infection of small pouches known as diverticular which develop along the intestinal walls. This infection results in small abscess along the intestinal lining together with massive perforations of the bowel (Chuong et al., 2016). It results in cramping of the left side of the abdomen and diarrhea in addition to the presence of bright red blood in the patient’s stool, which is positive in the provided case. Other symptoms include fever, nausea, and vomiting.
- Chron’s: it is a type of inflammatory bowel disease caused by inflammation of the GI tract. It presents mostly with abdominal pain, severe diarrhea and bloody stool of which the patient is positive for (Zafar et al., 2015). Other sign and symptoms include fever, fatigue, mouth sores, anorexia, weight loss and fistula around the anal region.
- Ulcerative colitis: It is an inflammatory condition of the colon, rectum or both areas, with ulceration of the colon lining (Bonovas et al., 2018). Patients with this condition usually complain of symptoms such as abdominal pain, severe diarrhea, and bloody stool just like the patient in the above case study. Other symptoms include rectal pain, the urgency to defecate, weight loss, fever, fatigue, and inability to defecate despite the urgency.
PLAN: N/A
References
Mayumi, T., Yoshida, M., Tazuma, S., Mizooka, M., Furukawa, A., Nishii, O., Shigematsu, K., … Hirata, K. (January 01, 2016). The Practice Guidelines for Primary Care of Acute Abdomen 2015. Japanese Journal of Radiology, 34, 1, 80-115.
Jamal, T. A., Edna, T.-H., Jamal, T. A., Edna, T.-H., Endreseth, B. H., Endreseth, B. H., & Lydersen, S. (January 01, 2017). Clinical diagnostic accuracy of acute colonic diverticulitis in patients admitted with acute abdominal pain, a receiver operating characteristic curve analysis. International Journal of Colorectal Disease, 32, 1, 41-47.
Othman, A. E., Bongers, M. N., Zinsser, D., Schabel, C., Wichmann, J. L., Arshid, R., Notohamiprodjo, M., … Bamberg, F. (April 13, 2017). Evaluation of reduced-dose CT for acute non-traumatic abdominal pain: evaluation of diagnostic accuracy in comparison to standard-dose CT. Acta Radiologica, 59, 1, 4-12.
Zafar, H. M., Chadalavada, S. C., Kahn, C. E., Cook, T. S., Sloan, C. E., Lalevic, D., Schnall, M. D., … Langlotz, C. P. (September 01, 2015). Code abdomen: An assessment coding scheme for abdominal imaging findings possibly representing cancer. Journal of the American College of Radiology, 12, 9, 947-950.
Chuong, A. M., Corno, L., Beaussier, H., Boulay-Coletta, I., Millet, I., Hodel, J., Taourel, P., … Zins, M. (January 01, 2016). Assessment of Bowel Wall Enhancement for the Diagnosis of Intestinal Ischemia in Patients with Small Bowel Obstruction: Value of Adding Unenhanced CT to Contrast-enhanced CT. Radiology, 280, 1, 98-107.
Bonovas, S., Lytras, T., Nikolopoulos, G., Peyrin-Biroulet, L., & Danese, S. (January 01, 2018). Systematic review with network meta-analysis: comparative assessment of tofacitinib and biological therapies for moderate-to-severe ulcerative colitis. Alimentary Pharmacology & Therapeutics, 47, 4, 454-465.
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:
Week 6 Assignment 1
Grading Rubric
| Performance Category | 100% or highest level of performance
100% 16 points |
Very good or high level of performance
88% 14 points |
Acceptable level of performance
81% 13 points |
Inadequate demonstration of expectations
68% 11 points |
Deficient level of performance
56% 9 points
|
Failing level
of performance 55% or less 0 points |
| Total Points Possible= 50 | 16 Points | 14 Points | 13 Points | 11 Points | 9 Points | 0 Points |
| Scholarliness
Demonstrates achievement of scholarly inquiry for professional and academic topics. |
Presentation of information was exceptional and included all of the following elements:
|
Presentation of information was good, but was superficial in places and included all of the following elements:
|
Presentation of information was minimally demonstrated in all of the following elements:
|
Presentation of information is unsatisfactory in one of the following elements:
|
Presentation of information is unsatisfactory in two of the following elements:
|
Presentation of information is unsatisfactory in three or more of the following elements
|
| 16 Points | 14 Points | 13 Points | 11 Points | 9 Points | 0 Points | |
| Application of Course Knowledge
Demonstrate the ability to analyze and apply principles, knowledge and information learned in the outside readings and relate them to real-life professional situations |
Presentation of information was exceptional and included all of the following elements:
|
Presentation of information was good, but was superficial in places and included all of the following elements:
|
Presentation of information was minimally demonstrated in the all of the following elements:
|
Presentation of information is unsatisfactory in one of the following elements:
|
Presentation of information is unsatisfactory in two of the following elements:
|
Presentation of information is unsatisfactory in three of the following elements
|
| 10 Points | 9 Points | 6 Points | 0 Points | |||
| Interactive Dialogue
Initial post should be a minimum of 300 words (references do not count toward word count) The peer and instructor responses must be a minimum of 150 words each (references do not count toward word count) Responses are substantive and relate to the topic. |
Demonstrated all of the following:
|
Demonstrated 3 of the following:
|
Demonstrated 2 of the following:
|
Demonstrated 1 or less of the following:
|
||
| 8 Points | 7 Points | 6 Points | 5 Points | 4 Points | 0 Points | |
| Grammar, Syntax, APA
Points deducted for improper grammar, syntax and APA style of writing. The source of information is the APA Manual 6th Edition Error is defined to be a unique APA error. Same type of error is only counted as one error. |
The following was present:
AND
AND
|
The following was present:
AND/OR
AND/OR
|
The following was present:
AND/OR
AND/OR
|
The following was present:
AND/OR
AND/OR
|
The following was present:
AND/OR
AND/OR
AND/OR
|
The following was present:
AND/OR
AND/OR
|
| 0 Points Deducted | 5 Points Lost | |||||
| Participation
Requirements |
Demonstrated the following:
|
Failed to demonstrate the following:
|
||||
| 0 Points Lost | 5 Points Lost | |||||
| Due Date Requirements | Demonstrated all of the following:
A minimum of one peer and one instructor responses are to be posted within the course no later than Sunday, 11:59 pm MT. |
Demonstrates one or less of the following.
A minimum of one peer and one instructor responses are to be posted within the course no later than Sunday, 11:59 pm MT. |