Assignment 1: Lab Assignment: Assessing the Abdomen NURS 6512

Assignment 1: Lab Assignment: Assessing the Abdomen NURS 6512

Assignment 1: Lab Assignment: Assessing the Abdomen NURS 6512

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Assessment of the Abdomen and Gastrointestinal System

The gastrointestinal system, as well as other organs such as the kidneys and spleen, are housed in the abdominal compartment, which is located between the thorax and pelvis. Physiologic disturbances in the abdomen and gastrointestinal system result in a variety of pathologies ranging in severity from mild to life-threatening. As a result, clinical evaluation of the abdomen and gastrointestinal system is critical to assisting in the rapid diagnosis of these pathologies and the initiation of the necessary therapeutic approaches. This paper will look at a case study of LZ, a 65-year-old African-American male who comes to the emergency room with a two-day history of epigastric pain radiating to the back. The following paragraphs will go over subjective and objective details, as well as an evaluation of this case scenario.

Subjective

LZ presents with a two-day history of sudden onset intermittent epigastric pain radiating to the back. Despite the use of proton pump inhibitors, the pain has persisted. However, he reports an increase in severity and vomiting despite the absence of fever or diarrhea. Epigastric abdominal pain is a general symptom that can be caused by both gastrointestinal and non-gastrointestinal causes. As a result, additional evaluation is necessary, and the additional history to inquire about the history of the presenting illness includes the following: The nature of the pain must be mentioned because some pathologies cause sharp pain while others cause colicky pain. Similarly, it is critical to inquire about the onset of the pain. For example, if it is worse at any given time of day. Factors that aggravate and relieve pain provide important information about the underlying etiology. As a result, it is worthwhile to inquire about the effects of a change in position on pain. For example, if it is worse or better in any specific position. Similarly, noting the effect of food on pain is essential.

Because most pathologies that cause epigastric pain also cause other symptoms, associated factors are important. Aside from fever and diarrhea, other symptoms that must be addressed include cough, chest pain, nausea, anorexia, hematuria, hematemesis, bloating, belching, nocturnal pain, indigestion, weight loss, dizziness, diaphoresis, anxiety, and bowel changes. LZ also vomited after eating his lunch. Because vomiting is a non-specific symptom, other questions to ask include the number of episodes, the constituents, the amount, and the color of the vomitus, whether other family members who ate the same meal vomited, and any associated factors. A history of medication use, particularly NSAIDs, steroids, and anticonvulsants, among others, a history of trauma, and a nutritional history, including diet and exercise, are all important aspects of history.

LZ also has a history of hypertension, hyperlipidemia, and GERD, as well as a drinking and smoking history. The aforementioned factors are thought to be significant risk factors for a variety of gastrointestinal pathologies. As a result, it is critical to quantify both smoking and alcohol consumption and to determine whether blood pressure and hyperlipidemia are well controlled. Finally, inquire as to whether he is stressed as a result of his divorce.

Objective

The analysis of the vital signs demonstrates that LZ with a blood pressure of 91/60 mmHg is hypotensive since he is a known hypertensive patient on metoprolol. Similarly, he is overweight which carries moderate health risks. The respiratory, dermatological, and cardiovascular systems revealed no abnormalities. Nevertheless, exhaustive examination with regards to inspection, palpation, auscultation, and percussion is crucial, particularly for the chest. auscultation particularly for the chest Findings noted on the abdominal exam include tenderness in the epigastric area with guarding although no masses or rebound tenderness. Additional features that are crucial to highlight in the physical examination include the general exam which focuses on the general appearance of the patient. Similarly, a detailed abdominal examination including comprehensive findings on auscultation, inspection, palpation, and percussion is crucial since different diseases present with different abdominal signs. Finally, a neurological examination is also significant as vomiting can be a manifestation of neurologic disease.

Assessment

Investigations necessary to assist in the diagnosis of his condition and rule out other causes of epigastric pain include both laboratory and radiological studies. Laboratory investigations include complete blood count with differential, urea, creatinine, and electrolytes, liver function tests, coagulation profile, serum amylase, and lipase levels, ESR/CRP, procalcitonin, blood glucose levels, LDH, lactate levels, serum triglycerides, calcium levels, stool for H. pylori antigen, and serum gastrin levels. The abovementioned laboratory tests are vital in evaluating the common causes of epigastric pain radiating to the back such as acute pancreatitis and peptic ulcer disease (Patterson et al., 2022).

On the other hand, imaging tests include ECG to rule out pericarditis, abdominal ultrasound to check for gallstones, liver or renal problems, abdominal X-ray which may reveal pneumoperitoneum in the case of a perforated ulcer, Chest X-ray and CT thorax, abdomen and Pelvis to identify possible pancreatitis and abdominal aortic aneurysm (Patterson et al., 2022). Finally, endoscopy is critical as both GERD and peptic ulcer disease are possible differentials.

Abdominal aortic aneurysm, acute pancreatitis, and perforated peptic ulcer are among the potential diagnosis for LZ’s presentation. Abdominal aortic aneurism refers to focal dilatation of the abdominal aorta to more than 1.5 times its ordinary diameter (Sakalihasan et al., 2018). Predisposing factors for this condition include advanced age, smoking, arterial hypertension, and hypercholesterolemia which LZ possesses (Sakalihasan et al., 2018). It is usually asymptomatic but may present with epigastric pain radiating to the back and pulsatile abdominal mass. A perforated peptic ulcer is another possible cause of his symptoms. Peptic ulcer disease shares similar risk factors as GERD including alcohol use and smoking. Psychological stress probably due to divorce is also a risk factor. The patient usually presents with epigastric pain which may radiate to the back. However, if perforated, features of peritonitis such as tenderness and guarding may be evident with no palpable mass (Malik et al., 2022). Acute pancreatitis similarly manifests with severe epigastric pain radiating to the back, abdominal tenderness, guarding, and nausea and vomiting (Shah et al., 2018). Additionally, LZ has a history of alcohol use and hyperlipidemia which may precipitate pancreatitis.

The other possible differential diagnoses for his condition include causes of acute abdomen particularly those causing epigastric pain such as acute mesenteric ischemia, myocardial infarction, acute gastritis, and Mallory Weiss syndrome (Patterson et al., 2022). For instance, acute mesenteric ischemia may present with epigastric pain, diarrhea, nausea and vomiting, and signs of peritonitis while Mallory Weiss syndrome manifests with epigastric pain/back pain, hematemesis, and signs of shock. Finally, myocardial infarction at times manifests as epigastric pain accompanied by nausea and vomiting, dizziness, dyspnea with exertion, and diaphoresis (Saleh & Ambrose, 2018). This is a potential differential diagnosis as LZ has risk factors for cardiovascular disease such as hypertension, smoking, alcohol use, and hyperlipidemia.

Conclusion

Meticulous evaluation of the abdominal and gastrointestinal systems is essential as it may point out an underlying diagnosis. Abdominal pain is a very non-specific symptom and may result from gastrointestinal or non-gastrointestinal causes. However, severe epigastric pain radiating to the back may be an indication of abdominal aortic aneurysm, acute pancreatitis, and perforated peptic ulcer.

References

Malik, T. F., Gnanapandithan, K., & Singh, K. (2022). Peptic ulcer disease. https://pubmed.ncbi.nlm.nih.gov/30521213/

Patterson, J. W., Kashyap, S., & Dominique, E. (2022). Acute Abdomen. https://pubmed.ncbi.nlm.nih.gov/29083722/

Sakalihasan, N., Michel, J.-B., Katsargyris, A., Kuivaniemi, H., Defraigne, J.-O., Nchimi, A., Powell, J. T., Yoshimura, K., & Hultgren, R. (2018). Abdominal aortic aneurysms. Nature Reviews. Disease Primers, 4(1), 34. https://doi.org/10.1038/s41572-018-0030-7

Saleh, M., & Ambrose, J. A. (2018). Understanding myocardial infarction. F1000Research, 7, 1378. https://doi.org/10.12688/f1000research.15096.1

Shah, A. P., Mourad, M. M., & Bramhall, S. R. (2018). Acute pancreatitis: current perspectives on diagnosis and management. Journal of Inflammation Research, 11, 77–85. https://doi.org/10.2147/JIR.S135751

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.

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.

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

Assignment 1: Lab Assignment: Assessing the Abdomen NURS 6512

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.

Abdominal Assessment

      Assignment 1: Lab Assignment: Assessing the Abdomen NURS 6512

Nurses and other healthcare providers play an important role in the promotion of health of diverse patient populations. They utilize their knowledge and skills in patient assessment to determine the actual and potential health needs of their patients. Abdominal health problems are part of the conditions that nurses address in their daily practice. Therefore, this essay examines a case study of a patient that came with abdominal health problem. The patient is a 47-year-old male that complained of generalized abdominal pain, which started 3 days ago. The essay examines the additional subjective and objective data that should be obtained from the patient, diagnostic investigations, and differential diagnoses that should be considered.

Subjective Analysis

Subjective information mostly refers to data obtained by healthcare providers regarding the experiences of people with a health problem. Subjective data investigates a wide range of characteristics of a condition, such as the patient’s concerns and sentiments. JR should provide a variety of subjective information. One of them is the abdominal pain’s personality. Aside from the degree and grade of the stomach discomfort, questions about aggravating, precipitating, and alleviating variables should be acquired. There is also a need to learn whether the pain is generalized, radiating to other parts of the body, rising or reducing in severity, or not. It is also necessary to get information about the pain, such as whether it is progressive or sudden in start. More information on the diarrhea should also be gathered. For example, the number and frequency of diarrhea episodes each day should be recorded. This is significant since it offers information on the patient’s hydration status. It is also necessary to acquire information on the factors that aggravate, precipitate, and relieve diarrhea (Perry et al., 2021). To discover the likely source of the health problem, the recent dietary history and habits should be investigated. According to the JR’s background, he has a history of gastrointestinal bleeding. To discover the actual origin of the problem, it is critical to ask questions about whether there is blood in the feces, the smell, and the color. Comprehensive subjective information collection is thus critical for guiding the creation of the most accurate JR diagnosis.

Objective Analysis

Objective data refers to the information that the healthcare provider obtains through physical examination. It entails the use of techniques such as observation, auscultation, percussion, and palpation. Objective data is mainly used to validate subjective data and develop accurate diagnosis of a problem affecting a client. A number of objective data needs to be obtained from the client in the case study. The first aspect of objective data is documenting the general appearance of JR. Information about the general appearance of the patient such as if well dressed and sick looking should have been obtained. Patients with chronic illnesses such as colon cancer may appear lethargic and malnourished. JR should have also been examined for jaundice and hydration status. Inspection of the abdomen should also be done to determine whether there is abdominal distention. Abdominal distention may lead to the development of diagnoses such as organomegally or pancreatic cancer. Observation should also aim at determining if there are any scars and distended veins. Palpation should also be done to determine if there is abdominal rigidity, tenderness, or rebound tenderness. Rigidity could indicate accumulation of fluid or abdominal matter in the peritoneal cavity, hence bowel obstruction (Cox, 2019). Therefore, the above objective data would guide the development of accurate diagnosis for the client.

If the Assessment is supported by Subjective and Objective Information

The assessment in the case study is supported by objective and subjective information. As noted initially, subjective data focuses on the perceptions and feelings of the patient with a disease. JR reported subjective data such as diarrhea and vomiting. He also reported pain and history of GI bleeding. Objective data focuses on the information that the healthcare provider obtains through physical assessment (Estes et al., 2019). The data such as vital signs, absence of murmurs, and intact skin without lesions are some of the objective information in the case study.

Assignment 1: Lab Assignment: Assessing the Abdomen NURS 6512

Diagnostic Tests

Additional diagnostic tests should be performed to come up with an accurate diagnosis of the health problem that the client in the case study is experiencing. One of the tests would be stool occult test to determine if there is blood in the stool or not. The other test is complete blood count to determine if the client has infection. Liver function tests may also be performed to determine whether there is an abnormality with liver enzymes, which indicate liver disease. Ultrasound of the abdomen may also be needed to view the abdominal organs for any abnormality (Williams, 2021).

Accepting or Rejecting Diagnosis and Possible Conditions

I would reject the diagnosis. The assessment was not comprehensive. For example, it did not examine the lower quadrant pain to determine its character. The subjective data points towards a possible diagnosis of gastroenteritis. The presence of abdominal pain, low-grade fever, vomiting and nausea are often associated with gastroenteritis. One of the differential diagnoses for JR in this case study is abdominal obstruction. Patients with abdominal obstruction often experience symptoms such as abdominal pains, vomiting, nausea, and vomiting. However, this condition is least likely due to the presence of diarrhea (Perry et al., 2021). The other possible differential diagnosis is pancreatic cancer. Patients with pancreatic cancer may experience symptoms such as abdominal pains, nausea, and vomiting. However, this should be ruled out by performing comprehensive history taking and physical examination. Diagnostic investigations such as abdominal ultrasound will help determine if JR is suffering from pancreatic cancer. The last differential diagnosis is diverticulitis. Diverticulitis is also associated with left lower quadrant pain, nausea, fever, and vomiting (Williams, 2021). The condition should be ruled out through a CT scan of the abdomen.

Conclusion

In conclusion, comprehensive assessment and physical examination is important in patient care. Additional subjective and objective data should be obtained from the patient in the case study to develop an accurate diagnosis. In addition, diagnostic investigations should be done to determine the actual cause of the abdominal problem. Differential diagnoses should be considered to guide the development of the treatment plan.

By Day 7 of Week 6

Submit your Lab Assignment.

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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

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Week 6 Assignment 1 Rubric

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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

Rubric Detail

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Name: NURS_6512_Week_6_Assignment_1_Rubric
Grid View
List View
Excellent Good Fair Poor
With 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.
10 (10%) – 12 (12%)
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.
7 (7%) – 9 (9%)
The response accurately analyzes the subjective portion of the SOAP note and lists additional information to be included in the documentation.
4 (4%) – 6 (6%)
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.
0 (0%) – 3 (3%)
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.
Analyze the objective portion of the note. List additional information that should be included in the documentation.
10 (10%) – 12 (12%)
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.
7 (7%) – 9 (9%)
The response accurately analyzes the objective portion of the SOAP note and lists additional information to be included in the documentation.
4 (4%) – 6 (6%)
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.
0 (0%) – 3 (3%)
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.
Is the assessment supported by the subjective and objective information? Why or why not?
14 (14%) – 16 (16%)
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.
11 (11%) – 13 (13%)
The response accurately identifies whether or not the assessment is supported by the subjective and/or objective information, with an explanation.
8 (8%) – 10 (10%)
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.
0 (0%) – 7 (7%)
The response inaccurately identifies whether or not the assessment is supported by the subjective and/or objective information, with an inaccurate or missing explanation.
What diagnostic tests would be appropriate for this case, and how would the results be used to make a diagnosis?
18 (18%) – 20 (20%)
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.
15 (15%) – 17 (17%)
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.
12 (12%) – 14 (14%)
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.
0 (0%) – 11 (11%)
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.
· 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.
23 (23%) – 25 (25%)
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.
20 (20%) – 22 (22%)
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.
17 (17%) – 19 (19%)
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.
0 (0%) – 16 (16%)
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.
Written 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 (5%) – 5 (5%)
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 (4%) – 4 (4%)
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 (3%) – 3 (3%)
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.
0 (0%) – 2 (2%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity < 60% of the time. No purpose statement, introduction, or conclusion were provided.
Written Expression and Formatting – English writing standards:
Correct grammar, mechanics, and proper punctuation
5 (5%) – 5 (5%)
Uses correct grammar, spelling, and punctuation with no errors.
4 (4%) – 4 (4%)
Contains a few (1 or 2) grammar, spelling, and punctuation errors.
3 (3%) – 3 (3%)
Contains several (3 or 4) grammar, spelling, and punctuation errors.
0 (0%) – 2 (2%)
Contains many (≥ 5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding.
Written 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 (5%) – 5 (5%)
Uses correct APA format with no errors.
4 (4%) – 4 (4%)
Contains a few (1 or 2) APA format errors.
3 (3%) – 3 (3%)
Contains several (3 or 4) APA format errors.
0 (0%) – 2 (2%)
Contains many (≥ 5) APA format errors.
Total Points: 100
Name: NURS_6512_Week_6_Assignment_1_Rubric