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

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

Sample Answer for NURS 6512: Week 6 Assignment 1: Lab Assignment: Assessing the Abdomen Included After Question

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

Learning Objectives – Week 6: Assessment of the Abdomen and Gastrointestinal System

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

Photo Credit: Hill Creek Pictures/UpperCut Images/Getty Images

Learning Resources – Week 6: Assessment of the Abdomen and Gastrointestinal System

Note: To access this week’s required library resources, please click on the link to the Course Readings List, found in the Course Materials section of your Syllabus.

Required Readings

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.

    • Chapter 4, “Vital Signs and Pain Assessment” (pp. 50-63)This chapter describes the experience of pain and its causes. The authors also describe the process of pain assessment. NURS 6512 Week 6: Assessment of the Abdomen and Gastrointestinal System.

 

  • Chapter 17, “Abdomen” (pp. 370-415)In this chapter, the authors summarize the anatomy and physiology of the abdomen. The authors also explain how to conduct an assessment on the abdomen.

Dains, J. E., Baumann, L. C., & Scheibel, P. (2016). Advanced health assessment and clinical diagnosis in primary care (5th ed.). St. Louis, MO: Elsevier Mosby.

    • Chapter 3, “Abdominal Pain” (pp. 11-32)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” (pp. 110-117)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” (pp. 133-147)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” (pp. 344-356)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.

Sullivan, D. D. (2019). Guide to clinical documentation (3rd ed.). Philadelphia, PA: F. A. Davis.

  • Chapter 10, “Admitting a Patient to the Hospital” (pp. 217-238)

Note: Download this Adult Examination Checklist and Abdomen Physical Exam Summary to use during your practice abdominal examination.

Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2011). Adult examination checklist: Guide for abdominal assessment. In Mosby’s guide to physical examination (7th ed.). St. Louis, MO: Elsevier Mosby.

This Adult Examination Checklist: Guide for Abdominal Assessment was published as a companion to Seidel’s guide to physical examination (8th ed.), by Ball, J. W., Dains, J. E., & Flynn, J. A. Copyright Elsevier (2015). From https://evolve.elsevier.com/

Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2011). Physical exam summary: Abdomen. In Mosby’s guide to physical examination (7th ed.). St. Louis, MO: Elsevier Mosby.

This Abdomen Physical Exam Summary was published as a companion to Seidel’s guide to physical examination (8th ed.), by Ball, J. W., Dains, J. E., & Flynn, J. A. Copyright Elsevier (2015). From https://evolve.elsevier.com/

University of Virginia. (n.d.). Introduction to radiology: An online interactive tutorial. Retrieved from http://www.med-ed.virginia.edu/courses/rad/index.html. This website provides an introduction to radiology and imaging. For this week, focus on gastrointestinal radiology.

Required Media

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 Chapters 7, and 17 that relate to the assessment of the abdomen and gastrointestinal system. Refer to Week 4 for access instructions on https://evolve.elsevier.com/. NURS 6512 Week 6: Assessment of the Abdomen and Gastrointestinal System.

Optional Resources- Week 6: Assessment of the Abdomen and Gastrointestinal System

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. NURS 6512 Week 6: Assessment of the Abdomen and Gastrointestinal System.

A woman went to the emergency room for severe abdominal cramping. She was diagnosed with diverticulitis; however, as a precaution, the doctor ordered a CAT scan. The CAT 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 assignment, you will analyze a SOAP 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.

Abdominal Assessment

SUBJECTIVE:

  • CC: “My stomach hurts, I have diarrhea and nothing seems to help.”
  • HPI: JR, 47 yo WM, complains of having generalized abdominal pain that started 3 days ago. He has not taken any medications because he did not know what to take. He states the pain is a 5/10 today but has been as much as 9/10 when it first started. He has been able to eat, with some nausea afterwards.
  • PMH: HTN, Diabetes, hx of GI bleed 4 years ago
  • Medications: Lisinopril 10mg, Amlodipine 5 mg, Metformin 1000mg, Lantus 10 units qhs
  • Allergies: NKDA
  • FH: No hx of colon cancer, Father hx DMT2, HTN, Mother hx HTN, Hyperlipidemia, GERD
  • Social: Denies tobacco use; occasional etoh, married, 3 children (1 girl, 2 boys)

OBJECTIVE:

  • VS: Temp 99.8; BP 160/86; RR 16; P 92; HT 5’10”; WT 248lbs
  • Heart: RRR, no murmurs
  • Lungs: CTA, chest wall symmetrical
  • Skin: Intact without lesions, no urticaria
  • Abd: soft, hyperctive bowel sounds, pos pain in the LLQ
  • Diagnostics: None
  • NURS 6512 Week 6: Assessment of the Abdomen and Gastrointestinal System

ASSESSMENT:

  • Left lower quadrant pain
  • Gastroenteritis
  • PLAN: This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.

To prepare:

With regard to the SOAP 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.

To complete:

  1. Analyze the subjective portion of the note. List additional information that should be included in the documentation.
  2. Analyze the objective portion of the note. List additional information that should be included in the documentation.
  3. Is the assessment supported by the subjective and objective information? Why or Why not?
  4. What diagnostic tests would be appropriate for this case and how would the results be used to make a diagnosis?
  5. 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 3 different references from current evidence based literature.

By Day 7

This assignment is due.

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Week 6 Assignment Rubric

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A Sample Answer For the Assignment: NURS 6512: Week 6 Assignment 1: Lab Assignment: Assessing the Abdomen  

Title: NURS 6512: Week 6 Assignment 1: Lab Assignment: Assessing the Abdomen  

The SOAP note is about a 47-year-old male with abdominal pain and diarrhea. He has had generalized abdominal pain for three days but has not taken any meds to relieve the pain. He reports that the pain was initially at 9/10 but has reduced to 5/10, and he cannot eat due to ensuing nausea. His medical history is positive for hypertension, DM, and GI bleeding. Examination of the abdomen reveals a soft abdomen, increased bowel sounds, and LLQ pain. The purpose of this assignment is to examine the SOAP note and discuss pertinent diagnostic tests and differential diagnoses. 

Subjective Portion 

The HPI should have given an additional description of the abdominal pain, particularly the duration of the abdominal pain, timing (before, during, or after meals), and frequency. In addition, it should describe the pain’s characteristics, for example whether it is crampy, piercing, dull, colicky, radiating, diffuse, or stable (Sokic-Milutinovic et al., 2022). In addition, the HPI should have included the exacerbating and alleviating factors for the abdominal pain and to what level the alleviating factors relieve the pain. Furthermore, the HPI has described only the abdominal pain leaving out diarrhea. It should describe diarrhea, including the onset, timing, frequency, characteristics of the stools (watery, mucoid, bloody, greasy, or malodorous), and relieving and aggravating factors.  

The subjective part should have included the patient’s immunization status with a focus on the last Tdap, Influenza, and COVID shots and surgical history. The social history has scanty information and should have included the patient’s education level, occupation, current living status, hobbies, exercise and sleep patterns, dietary habits, and health promotion interventions (Gossman et al., 2020). Lastly, a review of systems (ROS) is mandatory for a SOAP note. Thus, the SOAP note should have a ROS that indicates the pertinent positive and negative symptoms in each body system, which helps identify other symptoms the patient has not reported in the HPI.  

Objective Portion 

The objective part misses critical information like the findings from the general assessment of the patient, which should include the client’s general appearance, personal hygiene, grooming, dressing, speech, body language, and attitude towards the clinician. Moreover, the objective part should have physical exam findings from a focused abdominal exam. This includes findings from abdominal inspection, such as the pigmentation, symmetry, respiratory movements, contour, and visible masses. Additional auscultation findings that should be indicated include the presence of friction ribs, vascular sounds, and venous hum. It should also have exam findings from palpation and percussion, including abdominal tenderness, masses, organomegaly, guarding, or rebound tenderness (Sokic-Milutinovic et al., 2022). Besides, the liver span and spleen position should be indicated.  

Assessment 

The listed assessment findings are LLQ pain and gastroenteritis (GE). LLQ pain is supported by subjective findings of abdominal pain and LLQ tenderness on exam. GE is supported by symptoms of abdominal pain, diarrhea, and nausea and exam findings of low-grade fever and increased bowel sounds. 

Diagnostic Tests 

The diagnostic tests that should be ordered for this patient include stool culture, complete blood count (CBC), and abdominal ultrasound. A stool culture is crucial to look for ova and cyst, which will help establish the causative agent for diarrhea and guide the treatment plan. Based on the WBC count, the CBC will establish if the patient has an infection and if the infection is bacterial or viral (Sokic-Milutinovic et al., 2022). The abdominal ultrasound will be used to visualize abdominal organs and identify if there is inflammation that could be contributing to the patient’s GI symptoms.  

Differential Diagnoses 

GE is an acceptable diagnosis since the patient has classic symptoms of abdominal pain, diarrhea, nausea, mild fever, increased bowel sounds, and abdominal tenderness. Nevertheless, I would reject LLQ pain as a diagnosis because it is a physical exam finding and does not fit the description of a medical diagnosis. The likely diagnoses for this case are: 

Acute Viral Gastroenteritis 

Viral GE is a self-limiting diarrheal disorder attributed to infection by viruses. The common causative viruses arerotavirus, norovirus, enteric adenovirus, and astroviruses. Patients present with nausea, anorexia, vomiting, diarrhea (watery), abdominal pain and tenderness, mild fever, dehydration, and increased bowel sounds (Orenstein, 2020). Thus, Viral GE is a differential diagnosis owing to the patient’s nausea, abdominal pain, diarrhea, mild fever, increased bowel sounds, and abdominal tenderness. 

Ulcerative Colitis (UC) 

UC is a chronic inflammatory and ulcerative GI disorder that occurs in the colonic mucosa and is characterized by bloody diarrhea. Clinical symptoms include mild lower abdominal pain, bloody diarrhea, and bloody mucoid stools. Systemic manifestations include anorexia, nausea, fever, malaise, anemia, and weight loss (Porter et al., 2020). UC is a likely diagnosis due to positive findings of diarrhea, nausea, abdominal pain, and mild fever and the history of GI bleed.  

Colonic Diverticulitis 

Diverticulitis presents with inflammation of a diverticulum with the presence or absence of infection. Abdominal pain is the primary symptom of colonic diverticulitis. Patients present with LLQ abdominal pain and tenderness, which can sometimes be suprapubic and often have a palpable sigmoid. The abdominal pain is usually accompanied by fever, nausea, vomiting, and occasionally urinary symptoms (Swanson& Strate, 2018). Peritoneal signs like rebound and guarding can occur, especially with abscess or perforation. The patient’s nausea, mild fever, and LLQ pain makes Colonic diverticulitis a probable diagnosis.  

Conclusion 

The HPI in the objective portion should have described the characteristics of the abdominal pain and stated the onset, frequency, characteristics, and timing of diarrhea. A ROS should also be included with the patient’s positive and negative symptoms. The objective section should have comprehensive details of the abdominal exam findings. Diagnostic tests should include stool culture, CBC, and abdominal U/S. The likely diagnoses are Vital GE, Ulcerative colitis, and colonic diverticulitis. 

References 

Gossman, W., Lew, V., & Ghassemzadeh, S. (2020). SOAP Notes. In StatPearls [Internet]. StatPearls Publishing. 

Orenstein, R. (2020). Gastroenteritis, Viral. Encyclopedia of Gastroenterology, 652–657. https://doi.org/10.1016/B978-0-12-801238-3.65973-1 

Porter, R. J., Kalla, R., & Ho, G. T. (2020). Ulcerative colitis: Recent advances in the understanding of disease pathogenesis. F1000Research, 9, F1000 Faculty Rev-294. https://doi.org/10.12688/f1000research.20805.1 

Sokic-Milutinovic, A., Pavlovic-Markovic, A., Tomasevic, R. S., & Lukic, S. (2022). Diarrhea as a clinical challenge: General practitioner approach. Digestive Diseases, 40(3), 282-289.https://doi.org/10.1159/000517111 

Swanson, S. M., & Strate, L. L. (2018). Acute colonic diverticulitis. Annals of Internal Medicine, 168(9), ITC65–ITC80. https://doi.org/10.7326/AITC201805010 

A Sample Answer 2 For the Assignment: NURS 6512: Week 6 Assignment 1: Lab Assignment: Assessing the Abdomen  

Title: NURS 6512: Week 6 Assignment 1: Lab Assignment: Assessing the Abdomen  

Abdominal problems have adverse effects on the health and wellbeing of the patients. Nurses are expected to utilize their knowledge and skills in comprehensive history taking and patient assessment to develop accurate diagnoses and treatment plans for their patients. Therefore, this paper is an examination of J.R’s case study. J.R is a 47-year-old client that has come to the hospital with generalized abdominal pain for the last three days and nausea. The purpose of this paper is to examine the additional subjective and objective information to be obtained from the client, whether the case study has subjective and objective data, diagnostic investigations, and decision related to the developed diagnosis.

Analysis of Subjective Portion

Subjective data relates to that obtained from the patient. It focuses on the experiences of the patient with the health problem. Additional subjective information should be obtained from the patient to come up with an accurate diagnosis and treatment plan. One of the subjective data that should be obtained from the client is quantification of the abdominal pain. Information about the pain rating, severity, character, and relieving, precipitating, and aggravating factors should be obtained. The other aspect of the pain should focus on whether the pain is generalized, radiating to other body parts, or increasing or decreasing in intensity. The pain should also be described in terms of whether it is sudden or gradual.

Moreover, the nature of diarrhea that the client reports should also be quantified. A focus should be placed on aspects such as the frequency of the diarrhea in a given period to determine if they client is dehydrated or not. The additional information about diarrhea include color of stool, relieving, aggravating, and precipitating factors. The provider should also obtain information about the dietary history of the client. Food poisoning could be a factor to consider in this client’s case. As a result, information about recent dietary habits and perceived hygiene of the foods should be obtained to determine the cause of the problem. The hygiene status and source of water that the client drinks should be obtained to ascertain whether the problem is a water-borne disease. Since the client has history of gastrointestinal bleeding, it would be necessary to ask about recent changes in color, smell, and texture of the stool prior to the current problems (Jarvis & Eckhardt, 2019). Such information will aid in ruling out causes such as ulcers of the gastrointestinal system.

Analysis of Objective Position

Healthcare providers obtain objective data using methods such as observation, palpation, percussion, and auscultation. The data is important in confirming or validating the subjective data given by the patient. Additional objective data should be obtained from the client. They include the general appearance of the client during the first encounter with the healthcare provider. The healthcare provider should provide a description of the grooming, energy levels, body weight, and if the patient is dehydrated or not.  The provider should have also assessed the patient for hydration status and jaundice by checking on skin turgor and sclera for jaundice. The patient should have also provided comprehensive abdominal assessment to determine whether there is distention, bowel movements, organomegally, distention of veins, and scars. The provider should have also palpated the abdomen for tenderness, rigidity, or any rebound tenderness. The information could have helped rule out causes such as bowel obstruction and organomegally (Jarvis, 2019). The objective data could have facilitated the development of an accurate diagnosis for the client.

Analysis of the Assessment

Objective and subjective data support the assessment of JR. Examples of subjective data that supports the assessment include information about diarrhea, nausea, stomach pains, past medical, medication, allergies, family, and social histories. Examples of objective data include the vitals and heart, lungs, skin, and abdominal findings.

Diagnostic Tests

Stool test is the most appropriate diagnostic investigation for JR. Stool analysis should be performed to determine if the client has an infection or the cause could be due to gastrointestinal bleeding. Blood tests such as complete blood count are also recommended to determine if the client has low hemoglobin level due to bleeding or elevated white blood cell count to indicate infection. Since the client has a history of gastrointestinal bleeding, it would be appropriate to perform abdominal ultrasound to determine the actual cause of the problem (Jarvis & Eckhardt, 2019).

Rejecting/Accepting the Diagnosis

I would accept the current diagnosis. Patients with gastroenteritis experience symptoms similar to those of JR. The symptoms include abdominal cramps, vomiting, nausea, and diarrhea. The infection is short-term, implying symptom resolution over time. JR reports that the pain severity has declined, implying a potential symptom resolution in gastroenteritis. He also complains of diarrhea, abdominal pain, and nausea, hence, the decision to accept the diagnosis (Bányai et al., 2018). The differential diagnoses to be considered include abdominal obstruction, colon cancer, and inflammatory bowel disease. The above differentials have patients experiencing either nausea, vomiting, diarrhea, or abdominal pains. However, it may not be abdominal obstruction due to the presence of diarrhea and absence of abdominal distention. Diagnostic investigations such as abdominal ultrasound are needed to rule out colon cancer. The patient does not have any predisposition to environmental triggers, hence, ruling out inflammatory bowel disease (Guan, 2019).

Conclusion

Subjective and objective data guide the diagnoses developed for health problems affecting patients. JR is likely to be suffering from gastroenteritis. Additional subjective and objective data is however needed to develop an accurate diagnosis. Diagnostic investigations should be used to develop accurate diagnosis for the patient.

References

Bányai, K., Estes, M. K., Martella, V., & Parashar, U. D. (2018). Viral gastroenteritis. The Lancet, 392(10142), 175–186. https://doi.org/10.1016/S0140-6736(18)31128-0

Guan, Q. (2019). A Comprehensive Review and Update on the Pathogenesis of Inflammatory Bowel Disease. Journal of Immunology Research, 2019, e7247238. https://doi.org/10.1155/2019/7247238

Jarvis, C. (2019). Physical Examination & Health Assessment Access Code. Elsevier Health Sciences.

Jarvis, C., & Eckhardt, A. (2019). Physical Examination and Health Assessment. Elsevier.