see attached

 

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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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 Assessment of Pain;Skin,hair and nails.

• Define pain 
• Differentiate between acute pain and chronic pain. 
• Why do people have individualized responses to pain?

a.     Outline the steps involved in investigating pain as a present problem.

b.     List cultural considerations when taking a history and performing a physical examination related to pain.

• Which personal and social history factors should be explored in a patient in pain?
• When a patient complains of pain, how should it be assessed?    
• Describe how to determine cuff size in an adult patient.  
• Pain is known as which vital sign?  
• Why is it difficult to assess pain in older adults?  

Mr.  Hannigan is a 48-year-old man who presents to the emergency department  with a complaint of headache that has not been relieved in 3 days. He  now complains of visual disturbance and an inability to concentrate.

1. Describe the key indications when taking the blood pressure.

2. Describe the correct cuff size for a patient.

3. What signs and symptoms beside an elevated blood pressure would you expect the patient to exhibit?

Which  structure and its physiologic properties protect against microbial and  foreign substance invasion and minor physical trauma? 

How is hair formed, and what are its components? 

Which type of cells are nails, and into what will these cells convert?

Contrast differences between basal cell carcinoma, squamous cell carcinoma, malignant melanoma, and Kaposi sarcoma.

Describe the expected clinical manifestations of each condition. :

Primary lesions

a.             Macule

b.             Papule

c.             Nevi

d.             Patch

e.             Plaque

f.              Wheal

g.             Nodule

h.             Tumor

i.              Vesicle

j.              Bulla

k.             Pustule

l.              Cyst

m.            Vitiligo

n.             Rhinophyma

o.             Genital herpes

Secondary lesions

a.             Scale

b.             Lichenification

c.             Keloid

d.             Scar

e.             Excoriation

f.              Fissure

g.             Erosion

h.             Ulcer

i.              Crust

j.              Atrophy

JK  is a 44-year-old white woman with a 2-year history of psoriasis. Her  family history includes her father with allergies and asthma and her  mother with psoriasis. JK returns today for an increase in symptoms, and  she wants to improve the appearance of her skin.

1. What is the underlying cause of psoriasis?

2. What are the common signs and symptoms of this disease?

 

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You are admitting a 19-year old female college student to the   hospital for fevers.  Using the patient information provided,   choose a culture unfamiliar to you and describe what would be   important to remember while you interview this patient. Discuss the   health care support systems available in your community for someone of   this culture. If no support systems are available in your community,   identify a national resource.

 

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Maria’s vitals today are as follows; T 98.6, R 20, HR 88, BP 148/90

Using the lesson and text as your guide, answer the following questions.

1. What additional assessment data (subjective and/or objective) would you like to gather from Maria?
2. What actual health concerns and risk factors have you identified?
3. What are some opportunities to promote health and wellness for Maria?
4. Write one nursing diagnosis for Maria (actual, wellness or risk), based on one of the health concerns or opportunities you have identified. (Please use one of the formulas outlined in the text and lesson!)

 

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