Episodic Note Case Study:

Assessment of the Abdomen and Gastrointestinal System 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, hyperactive bowel sounds, pos pain in the LLQ • Diagnostics: None 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. 

Assignment: Assessing 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.

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. 

· With regard to the Episodic note case study provided:

o Review this week’s Learning Resources, and consider the insights they provide about the case study.

o Consider what history would be necessary to collect from the patient in the case study.

o 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?

o Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.

The Assignment

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 three different references from current evidence-based literature.

Resource for references

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.

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In this assignment, you will be exploring actual and potential health problems in the childhood years using a functional health assessment and Erickson’s Stages of Child Development. To complete this assignment, do the following:

1. Using the textbook, complete the “Children’s Functional Health Pattern Assessment.” Follow the instructions in the resource for completing the assignment.
2. Cite and reference any outside sources used in your answers. Include in your assessment a thorough discussion of Erickson’s Stages of Child Development as it pertains to the development age of the child.

While APA format is not required for the body of this assignment, solid academic writing is expected and in-text citations and references should be presented using APA documentation guidelines, which can be found in the APA Style Guide, located in the Student Success Center.

This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.

"Looking for a Similar Assignment? Get Expert Help at an Amazing Discount!"

In this assignment, you will be exploring actual and potential health problems in the childhood years using a functional health assessment and Erickson’s Stages of Child Development. To complete this assignment, do the following:

1. Using the textbook, complete the “Children’s Functional Health Pattern Assessment.” Follow the instructions in the resource for completing the assignment.
2. Cite and reference any outside sources used in your answers. Include in your assessment a thorough discussion of Erickson’s Stages of Child Development as it pertains to the development age of the child.

While APA format is not required for the body of this assignment, solid academic writing is expected and in-text citations and references should be presented using APA documentation guidelines, which can be found in the APA Style Guide, located in the Student Success Center.

This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.

You are not required to submit this assignment to Turnitin.

NRS-434VN-R-Childrens-functional-health-pattern-assessment-Student.docx
 

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• CO1 Utilize prior knowledge of theories and principles of nursing and related disciplines to explain expected client behaviors, while differentiating between normal findings, variations, and abnormalities. (PO 1)
• CO2 Recognize the influence that developmental stages have on physical, psychosocial, cultural, and spiritual functioning. (PO 1)
• CO3 Utilize effective communication when performing a health assessment. (PO 3)

Fred is an 83-year-old male who is being admitted to the medical-surgical unit status post fall. He is alert and oriented and reports that while visiting a local casino with his wife Margaret earlier this evening, he tripped over a curb and fell landing on his right side. After receiving morphine in the emergency room prior to transfer to your unit, Fred is rating his pain at 6/10. He has multiple bruises from his jawbone to his knee as well as a slight rotation of his right leg.

Past medical history includes: myocardial infarction (MI) x 2, peripheral vascular disease (PVD) with bilateral iliac stents, non-insulin-dependent diabetes mellitus (NIDDM), sleep apnea, and degenerative joint disease.

Medications include: aspirin, Plavix, Lopressor, Lisinopril, and Metformin.

After reviewing the above scenario please answer the following questions.

1. Based on the information provided, how will you prioritize your care, what assessments will you include and in what order? Please provide rationale for your response.
2. Considering this patient’s age, injury, past medical history, and list of current medications, what, if any, concerns do you have related to his potential need for surgery?
3. Should surgery to repair his right femur be required; what type of clearance and pre-op orders would you anticipate receiving related to his diet, meds, lab work, and so on?

STOPPED IN HIS TRACKS

CLASS: I am certain that most of you have encountered a patient like Fred.  They are vibrant and engaged elderly people who suffer a fall and sustain what can be life threatening injuries.  His situation is complicated by his age (the condition of his vital organs and musculoskeletal system), his previous medical history and his current medication regimen.   Be sure to consider each of these complications as you create your plan for his nursing care.  

References:

Chamberlain College of Nursing (2019) NR305 RN Health Assessment.Week 7 lesson Downers Grove, IL Online Publication

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