Assessing the Abdomen
Learning Objectives
- Evaluate abnormal abdomen and gastrointestinal findings
- Apply concepts, theories, and principles relating to health assessment techniques and diagnoses for the abdomen and gastrointestinal system
This week you will complete an analysis of the SOAP note provided. Please approach it as a narrative so that you will be able to correctly explain your analysis. Please review the instructions under learning resources on how to do this assessment
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
Always go back to the rubric. Start with the rubric, end with the rubric. Once you are finished with your paper, go back to the rubric. Can you pick out where you have clearly covered each of the required pieces?
Another important point, please use resources that are credible and scholarly. Do not use webmd, slide share or Wikipedia and or similar sources. These are not acceptable. Please for all assignments check your references, they should not be older than 5 years. Medicine and research change frequently, it is important that you’re using the most up to date and relevant sources.
A PARAGRAPH must have 3-5 complete sentences – Direct quote and block quotes.
Please do not use more than 1 quote in a 2-paragraph discussion. As per writing guidelines, in the written assignment please decrease the quotes to no more than 1-2 per page. Use quotes for statistics or definitions. Less is better!!! I would like to see what you think on an issue and then how you support it with evidence from the literature not vice versa. At graduate level, we focus on original thoughts not what someone else reiterates. Please avoid patching, which is the use of back-to-back quotes. Paraphrasing is recommended to demonstrate a synthesis of information.
A direct quote includes less than 40 words. That quote must end with either (author, year, and page #) or if the author and year are stated at the beginning of the sentence, (a page number) is a MUST at the end of the quote!!!! The period is placed after the parenthesis.
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 fivepossible conditions that may be considered in a differential diagnosis for the patient.
Health Assessment 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.
Learning Resources
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.
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
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.