Week 6 Assignment Lab Assignment: Assessing the Abdomen

NURS 6512 Week 6: Assessment of the Abdomen and Gastrointestinal System

Assignment 1: Lab 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. 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

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.

In this Assessment 1 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. Just add in what you want to this case to make it unique to you. Do not use NA or normal.

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: ?

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.

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 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.

Chabok, A., Thorisson, A., Nikberg, M., Schultz, J. K., & Sallinen, V. (2021). Changing paradigms in the management of acute uncomplicated diverticulitis. Scandinavian Journal of Surgery, 110(2), 180–186. https://doi.org/10.1177/14574969211011032

Hussein, A., Arena, A., Yu, C., Cirilli, A., & Kurkowski, E. (2021). Abdominal pain in the elderly patient: Point-of-care ultrasound diagnosis of small bowel obstruction. Clinical Practice and Cases in Emergency Medicine, 5(1), 127–128. https://doi.org/10.5811/cpcem.2020.11.50029

Sample Solution :

Assessing the Abdomen

Subjective Data

As per the case study, the client has been suffering from generalized stomach pain and diarrhea for the past three days. The pain is a 5/10 for him now, but it was as high as a 9/10 when it first started. He has not used any medicine. He also complains of feeling nauseous after a meal. More details on the frequency and features of the stomach discomfort should have been provided in the HPI section. Primarily, the client should be questioned about whether the abdomen discomfort is throbbing, sharp, burning, or colicky (Ball et al., 2019). In conjunction with nausea and constipation, additional information must be obtained on concomitant symptoms such as diarrhea, jaundice, and weight gain or loss. Because the client also has diarrhea, it is vital to get more details on the regularity, quantity, and consistency of the client’s bowel movements (Ball et al., 2019). Individuals with a history of hypertension and diabetes should be asked about their participation in physical activity and compliance with the stipulated diet, especially if they are overweight. The information obtained may be used to provide a foundation for educating patients about these two illnesses. According to Ball et al. (2019), further information should be obtained from the client’s individual and interpersonal background, such as if the client has recently traveled or whether he has been in contact with anybody who has a viral disease or foodborne illness.

Objective Data

The SOAP note’s objective part contained many of the systems necessary for a focused abdominal assessment. According to the results of the physical assessment, the client has a minor fever (99.8 F), and the abdomen assessment indicated hyperactive bowel movements besides discomfort in the left lower quadrant. Such results are symptomatic of diseases including diverticulitis, gastroenteritis, and/or blockage in the gastrointestinal tract (Patterson et al., 2020). Complete blood count (CBC) should be conducted to rule out anemia and leukocytosis since the client has had many episodes of gastrointestinal bleeding in the past. Rectal examination is also necessary to rule out the possibility of gastrointestinal bleeding and the illnesses that go along with it. Along with the recorded assessment findings, collected information on the client’s overall image, including facial expression and complexion, would be necessary (Ball et al., 2019). It is also necessary to give further details on the rebound, guarding, and palpation of masses in conjunction with the bowel sound examination (Patterson et al., 2020).

Assessment

The client was diagnosed with gastroenteritis and left lower quadrant abdominal discomfort. The subjective and objective information provides credence for gastroenteritis diagnosis. When the client is palpated in the left lower quadrant, he reports generalized abdominal pain. Both the subjective and objective information point to the second diagnosis as being correct, considering that this disease is linked to abdominal pain, hyperactive bowel sounds, abdominal tenderness, diarrhea, and nausea (Ball et al., 2019).

Diagnostics

In order to make a precise diagnosis, it is necessary to conduct diagnostic procedures. A complete blood count with differential would be necessary to rule out infection or loss of blood. An abdominal CT scan or ultrasound may be required to exclude intestinal blockage, appendicitis, or other conditions based on the fact that the client is reporting left lower quadrant discomfort on palpation (Patterson et al., 2020). An abdominal CT scan may aid in the evaluation of the abdominal wall, ureter, left kidney, and bowel, among other things. HbA1C, stool guaiac, and CMP are all that is needed in this case, considering the client’s history of diabetes and gastrointestinal bleeding.

Differential Diagnosis

Gastroenteritis: Given both objective and subjective information, I believe gastroenteritis has been correctly diagnosed. Indications of the illness include generalized stomach pain, diarrhea, and nausea, all of which are indications reported by JR Bowel sounds that are hyperactive are often observed during a physical exam (Australia, 2021).

Diverticulitis: When the diverticular membrane becomes inflamed and infected, this disease occurs. Considering that the client’s symptoms (abdominal pain and diarrhea) are present, this disease should be evaluated as a probable diagnosis (Young-Fadok, 2018). During a physical assessment, individuals with diverticulitis often report left lower quadrant discomfort on palpation. Rectal bleeding is uncommon in diverticulitis, but the presence of painless red bleeding might indicate diverticular hemorrhage (Young-Fadok, 2018).

 Bowel obstruction: This occurs when the intestines become obstructed due to a tumor, intestinal infection, or hernia. Hyperactive bowel movements, diarrhea, constipation, and abdominal pain are common indications and assessment results with this condition (Catena et al., 2019). When the colon is impacted, the client may complain of left lower quadrant discomfort when palpated.

Ulcerative Colitis. This is a chronic inflammatory bowel illness that affects the digestive tract and creates irritation. Only the inner wall of the rectum and colon is affected by ulcerative colitis. Rectal bleeding, bloody diarrhea, stomach pains, and soreness are among the symptoms of this condition (Gajendran et al., 2019).

References

Australia, H. (2021). Gastroenteritis. https://www.healthdirect.gov.au/gastroenteritis

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.

Catena, F., De Simone, B., Coccolini, F., Di Saverio, S., Sartelli, M., & Ansaloni, L. (2019). Bowel obstruction: A narrative review for all physicians. World Journal of Emergency Surgery, 14(1). https://doi.org/10.1186/s13017-019-0240-7

Gajendran, M., Loganathan, P., Jimenez, G., Catinella, A. P., Ng, N., Umapathy, C., Ziade, N., & Hashash, J. G. (2019). A comprehensive review and update on ulcerative colitis,. Disease-a-Month, 65(12), 100851. https://doi.org/10.1016/j.disamonth.2019.02.004

Patterson, J. W., Kashyap, S., & Dominique, E. (2020). Acute abdomen. StatPearls [Internet]

Young-Fadok, T. M. (2018). Diverticulitis. New England Journal of Medicine, 379(17), 1635-1642. https://doi.org/10.1056/nejmcp1800468

Rubric Detail Name: NURS_6512_Week_6_Assignment_1_Rubric

Select Grid View or List View to change the rubric’s layout.

Content