NURS 6512 Chamberlian University Assessing the Abdomen Research

Assignment 1: Lab Assignment: Assessing the Abdomen

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. NURS 6512 Chamberlian University Assessing the Abdomen Research

NURS 6512 Chamberlian University Assessing the Abdomen Research The Assignment

Examine the note’s subjective section. List any additional details that the documentation should contain.
Examine the note’s objective section. List any additional details that the documentation should contain.
Do the subjective and objective data support the assessment? If not, why not?
What diagnostic procedures are necessary in this situation, and how would the findings be applied to a diagnosis?
Would you disagree with the present diagnosis? If not, why not? Name three potential conditions that could be used in this patient’s differential diagnosis. Use at least three distinct references from the most recent works of evidence-based literature to support your arguments.

Assessment of the Abdomen and Gastrointestinal System

NURS 6512 Chamberlian University Assessing the Abdomen Research ABDOMINAL ASSESSMENT

SEE CASE STUDY BELOW

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, hyperactive bowel sounds, pos pain in the LLQ
Diagnostics: None

Assessment:

Left lower quadrant pain
Gastroenteritis

Learning Resources

NURS 6512 Chamberlian University Assessing the Abdomen Research Required Readings

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. NURS 6512 Chamberlian University Assessing the Abdomen Research

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. NURS 6512 Chamberlian University Assessing the Abdomen Research

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.

Document: Midterm Exam Review (Word document)

NURS 6512 Chamberlian University Assessing the Abdomen Research 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. NURS 6512 Chamberlian University Assessing the Abdomen Research
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 Chamberlian University Assessing the Abdomen Research Required Media

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/

NURS 6512 Chamberlian University Assessing the Abdomen Research