Assignment 1: Lab Assignment: Assessing the Abdomen NURS 6512N-32

 

Abdominal Assessment
Nurses and other healthcare providers play an important role in the promotion of the 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
Assignment 1 Lab Assignment Assessing the Abdomen NURS 6512N-32
study of a patient that came with an 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 refers mainly to the data that healthcare providers obtain concerning the experiences of patients with a health problem. Subjective data explores a wide range of aspects of a disease such as the concerns and feelings of the patient. A number of subjective information should be obtained from JR. One of them is the character of abdominal pain. Besides the rating and intensity of the abdominal pain, questions related to aggravating, precipitating, and relieving factors should be obtained. There is also a need to obtain information on whether the pain radiates to other parts of the body, generalized, increasing, or decreasing in severity or not. Information about the pain such as its character such as being gradual or of sudden onset should also be obtained. Additional information about diarrhea should also be obtained. For example, the frequency and number of diarrhea experienced in a day should be obtained. This is important as it provides clues into the hydration status of the patient. Information about the aggravating, precipitating, and relieving factors for diarrhea should also be obtained (Perry et al., 2021). Recent dietary history and habits should also be explored to determine the potential cause of the health problem. The history obtained from the JR indicates that he has a history of GI bleeding. It is therefore important to ask information related to whether there is a blood-stained stool, smell and color to determine the exact cause of the problem. Comprehensive acquisition of subjective information is, therefore, crucial to guide the development of the most accurate diagnosis for JR.
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 an 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 organomegaly 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 an 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 a 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.
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 a stool occult test to determine if there is blood in the stool or not. The other test is a complete blood count to determine if the client has an infection. Liver function tests may also be performed to determine whether there is an abnormality with liver enzymes, which indicates 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.

Assignment 1: Lab Assignment: Assessing the Abdomen

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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

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?

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

Week 7 Required Media

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

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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 107, “X-Ray Interpretation: Chest (pp. 480–487)
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.
Document: Midterm Exam Review (Word document)
Optional Resource
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.
Required Media (click to expand/reduce)
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

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