NURS 6512 Lab Assignment Assessing the Abdomen

NURS 6512 Lab Assignment Assessing the Abdomen

Abdominal Assessment

Abdominal problems have adverse effects on the health and wellbeing of the patients. Nurses are expected to utilize their knowledge and skills in comprehensive history taking and patient assessment to develop accurate diagnoses and treatment plans for their patients. Therefore, this paper is an examination of J.R’s case study. J.R is a 47-year-old client that has come to the hospital with generalized abdominal pain for the last three days and nausea. The purpose of this paper is to examine the additional subjective and objective information to be obtained from the client, whether the case study has subjective and objective data, diagnostic investigations, and decision related to the developed diagnosis.

Analysis of Subjective Portion

Subjective data relates to that obtained from the patient. It focuses on the experiences of the patient with the health problem. Additional subjective information should be obtained from the patient to come up with an accurate diagnosis and treatment plan. One of the subjective data that should be obtained from the client is quantification of the abdominal pain. Information about the pain rating, severity, character, and relieving, precipitating, and aggravating factors should be obtained. The other aspect of the pain should focus on whether the pain is generalized, radiating to other body parts, or increasing or decreasing in intensity. The pain should also be described in terms of whether it is sudden or gradual.

Moreover, the nature of diarrhea that the client reports should also be quantified. A focus should be placed on aspects such as the frequency of the diarrhea in a given period to determine if they client is dehydrated or not. The additional information about diarrhea include color of stool, relieving, aggravating, and precipitating factors. The provider should also obtain information about the dietary history of the client. Food poisoning could be a factor to consider in this client’s case. As a result, information about recent dietary habits and perceived hygiene of the foods should be obtained to determine the cause of the problem.

The hygiene status and source of water that the client drinks should be obtained to ascertain whether the problem is a water-borne disease. Since the client has history of gastrointestinal bleeding, it would be necessary to ask about recent changes in color, smell, and texture of the stool prior to the current problems (Jarvis & Eckhardt, 2019). Such information will aid in ruling out causes such as ulcers of the gastrointestinal system.

Analysis of Objective Position

Healthcare providers obtain objective data using methods such as observation, palpation, percussion, and auscultation. The data is important in confirming or validating the subjective data given by the patient. Additional objective data should be obtained from the client. They include the general appearance of the client during the first encounter with the healthcare provider. The healthcare provider should provide a description of the grooming, energy levels, body weight, and if the patient is dehydrated or not.

The provider should have also assessed the patient for hydration status and jaundice by checking on skin turgor and sclera for jaundice. The patient should have also provided comprehensive abdominal assessment to determine whether there is distention, bowel movements, organomegally, distention of veins, and scars. The provider should have also palpated the abdomen for tenderness, rigidity, or any rebound tenderness. The information could have helped rule out causes such as bowel obstruction and organomegally (Jarvis, 2019). The objective data could have facilitated the development of an accurate diagnosis for the client.

Analysis of the Assessment

Objective and subjective data support the assessment of JR. Examples of subjective data that supports the assessment include information about diarrhea, nausea, stomach pains, past medical, medication, allergies, family, and social histories. Examples of objective data include the vitals and heart, lungs, skin, and abdominal findings.

Diagnostic Tests

Stool test is the most appropriate diagnostic investigation for JR. Stool analysis should be performed to determine if the client has an infection or the cause could be due to gastrointestinal bleeding. Blood tests such as complete blood count are also recommended to determine if the client has low hemoglobin level due to bleeding or elevated white blood cell count to indicate infection. Since the client has a history of gastrointestinal bleeding, it would be appropriate to perform abdominal ultrasound to determine the actual cause of the problem (Jarvis & Eckhardt, 2019).

Rejecting/Accepting the Diagnosis

I would accept the current diagnosis. Patients with gastroenteritis experience symptoms similar to those of JR. The symptoms include abdominal cramps, vomiting, nausea, and diarrhea. The infection is short-term, implying symptom resolution over time. JR reports that the pain severity has declined, implying a potential symptom resolution in gastroenteritis. He also complains of diarrhea, abdominal pain, and nausea, hence, the decision to accept the diagnosis (Bányai et al., 2018).

The differential diagnoses to be considered include abdominal obstruction, colon cancer, and inflammatory bowel disease. The above differentials have patients experiencing either nausea, vomiting, diarrhea, or abdominal pains. However, it may not be abdominal obstruction due to the presence of diarrhea and absence of abdominal distention. Diagnostic investigations such as abdominal ultrasound are needed to rule out colon cancer. The patient does not have any predisposition to environmental triggers, hence, ruling out inflammatory bowel disease (Guan, 2019).

Conclusion

Subjective and objective data guide the diagnoses developed for health problems affecting patients. JR is likely to be suffering from gastroenteritis. Additional subjective and objective data is however needed to develop an accurate diagnosis. Diagnostic investigations should be used to develop accurate diagnosis for the patient.

References

Bányai, K., Estes, M. K., Martella, V., & Parashar, U. D. (2018). Viral gastroenteritis. The Lancet, 392(10142), 175–186. https://doi.org/10.1016/S0140-6736(18)31128-0

Guan, Q. (2019). A Comprehensive Review and Update on the Pathogenesis of Inflammatory Bowel Disease. Journal of Immunology Research, 2019, e7247238. https://doi.org/10.1155/2019/7247238

Jarvis, C. (2019). Physical Examination & Health Assessment Access Code. Elsevier Health Sciences.

Jarvis, C., & Eckhardt, A. (2019). Physical Examination and Health Assessment. Elsevier.

The SOAP note portrays a 65-year-old man who comes to the ED with a chief complaint of abdominal pain for the past two years. He has intermittent epigastric abdominal pain radiating to the back. The abdominal pain has worsened over the past hours, and he had one episode of vomiting after lunch. Physical exam findings include abdominal tenderness in the epigastric area with guarding but no abdominal mass or rebound present. The assessment findings are Abdominal Aortic Aneurysm (AAA), Perforated Ulcer, and Pancreatitis. The purpose of this assignment is to analyze the SOAP note and discuss the differential diagnoses for this case.

Subjective Portion

The HPI lacks information describing abdominal pain, like crampy, sharp, colicky, or dull. It should also have information on when the abdominal pain occurs, like pre- or post-prandial. Information on the abdominal pain relieving and aggravating factors should also be included (Rastogi et al., 2019). Besides, the HPI should have pain severity obtained by asking the patient to rate the pain on a pain rating scale. In addition, the subjective portion should have included the patient’s surgical history with dates of surgery and immunization history with dates of the last Flu and Tdap shots. Furthermore, the subjective portion lacks a review of systems (ROS), which should have the pertinent positives and negatives for all body systems. The ROS helps identify symptoms not stated in the HPI, which helps get a clear picture of the underlying disease.

Objective Portion

The objective part of the SOAP note does not have findings from the general assessment. This should include the patient’s general appearance, grooming, level of alertness, apparent state of health, comfort or distress, body language, and eye contact. As an abdominal assessment detailed findings from the abdomen assessment should be provided. This includes inspection findings like scars, abdomen symmetry, pigmentation, and movement with respiration (Rastogi et al., 2019). In addition, auscultation findings, including bowel sounds, vascular sounds, bruits, and friction rubs, should be included. Findings from the percussion of the abdomen, like the stomach, spleen, liver span, and kidney, should have been provided.

Assessment Portion

Enlarging aneurysms in AAA often cause flank, abdominal, or back pain. Abdominal palpation findings in AAA can include non-tender, pulsatile abdominal mass. Thus, the patient’s abdominal pain and tenderness support AAA. Clinical manifestations in a perforated ulcer include upper abdominal pain that can be localized to the left upper quadrant, right upper quadrant, or epigastrium (Tarasconi et al., 2020). Abdominal tenderness in the epigastric area supports perforated ulcer. Epigastric abdominal pain, tenderness, and guarding supports pancreatitis (Chatila et al., 2019).

Appropriate Diagnostic Tests

Appropriate diagnostic tests for this case include an abdominal ultrasound, complete blood count (CBC), and upper GI endoscopy. The CBC test will be necessary for assessing abdominal inflammation or infection through the WBC count. An abdominal ultrasound will be appropriate to determine the cause of the abdominal pain, including if there is an inflammation of the abdominal organs. In addition, an upper GI endoscopy will be used to detect inflammation and sores/ulcers in the upper GI tract.

Would You Reject/Accept The Current Diagnosis?

AAA does not qualify as a primary diagnosis since the patient does not have a non-tender, pulsatile abdominal mass, usually present in symptomatic patients. Besides, AA is usually symptomatic during a rupture, where patients present with constant pain and often get into frank shock (Hellawell et al., 2021). The patient has intermittent abdominal pain and has no signs of shock.

NURS 6512 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.

Introduction

The case scenario discussed in this post is the case of the 33-year-old Causcasan, who presents to the office to establish himself as a new patient.

Specific socioeconomic, spiritual, lifestyle, and other cultural factors associated with the patient

The patient, in this case, scenario, presents with different socioeconomic, spiritual, lifestyle, and other cultural factors that are important to consider so as to understand his overall health and well-being.

Socioeconomic Factors:

1. Unemployment: The patient reports being unemployed and living with his parents currently. This may contribute to financial difficulty, stress, and a potential burden on his family.
2. Health Insurance and  Access: The patient’s use of telehealth shows a level of access to health care, but reliance on obtaining free medications suggests that he may have limited access to adequate healthcare.
3. Support System: The patient has a family that is willing to support him at this time when he is unemployed and unwell, which is an indication of an available support system. However, given his financial health situation, he may benefit from other community resources and support.

Lifestyle Factors:

4. Current Smoker: The patient has smoked two packages of cigarettes per day over the past ten years, and this poses a significant health risk. Given his present report of possible declining health, one of the priorities for this patient is smoking cessation.
5. Marijuana Use: The patient’s regular marijuana use may have recreational or therapeutic purposes. It is important to understand the extent and impact of this usage on their physical and mental health.
6. Depression: The patient’s history of episodes of depression indicates a mental health condition that may influence his overall health, lifestyle, and ability to cope with daily challenges.

Cultural Factors:

7. Transgender: The patient’s transition from female to male may indicate a possible struggle for acceptance in his community. Transgender communities are still gaining popularity in many cultures, and they usually report a lack of acceptance and discrimination, even in healthcare settings (McAuliffe, Baker, and D’Aoust, 2023). This may affect the patient’s confidence to seek healthcare and support openly. Cultural factors surrounding gender identity, acceptance, and support from family, friends, and society at large may greatly impact their well-being.
8. HIV Status: The patient is HIV-positive and is obtaining his medications online, suggesting a possible feeling of isolation which could be related to the stigma associated with the disease. Cultural factors may influence their experiences of stigma, support, and access to appropriate care within the HIV community.

Spiritual Factors:

Sexual orientation: Changing from female to male indicates a significant aspect of his personality. The transition is hugely associated with the challenge of acceptance by family, peers, and the community, which likely plays a role in his overall well-being and spiritual fulfillment.

Sensitive issues to be aware of when interacting with the patient and why

When interacting with this patient, it is crucial to be sensitive to his mental health, gender identity, HIV status, substance abuse, financial status, and stigma issues due to their potential impact on the patient’s well-being and healthcare experience.

9. Mental Health: Research has shown that transgender individuals often face social and economic challenges that can affect their access to healthcare and lead to poorer mental health outcomes compared to cisgender individuals (Crissman, Stroumsa, Kobernik, and Berger, 2019). Given the patient’s history of depression, it is crucial to approach these issues with sensitivity and empathy. Being prepared to address his mental health concerns is important, as mental health issues can significantly impact his overall well-being and his ability to cope with his current circumstances.
10. Gender Identity and Transition: It is important to recognize and respect the patient’s new gender identity as male and use their preferred name and pronouns. Awareness of the potential challenges he may have faced during the transition and the need to validate his identity and experiences are crucial.
11. HIV Status: As an APRN, it is crucial to respect the patient’s privacy regarding his HIV status and acknowledge the fact that managing HIV can be emotionally and physically demanding, and be prepared to offer support, education, and appropriate healthcare referrals related to HIV management and care.
12. Stigma: According to research, transgender individuals often face discrimination, stigma, and social challenges not only in communities but also in healthcare settings (Kelly, 2021). As an APRN, it is important to avoid making assumptions or judgments based on stereotypes and create a safe and non-judgmental environment to foster trust and open communication (Ball et al., 2019).
13. Unemployment: When interacting with this patient, it is essential to recognize the potential stress and anxiety associated with the patient’s unemployment and financial dependency on their family. If appropriate, exploring resources or programs that may assist with employment opportunities or financial assistance will be helpful.
14. Substance Use: The patient’s use of marijuana and heavy smoking need to be approached with empathy and without judgment. As APRN, this issue is discussed in a non-confrontational manner, with the goal of understanding its impact on his health and exploring potential strategies for reducing or managing use.

Targeted questions to build his health history and assess his health risks

15. Can you share details of your gender transition journey and the timeline?
16. How have you been coping with your episodes of depression? Have you been seen by any professional or received any treatment for depression?
17. Are there any recent changes in your mental health that you would like us to talk about?
18. Can you tell me about your smoking habits? How many cigarettes do you smoke per day, and for how long have you been smoking?
19. Could you tell me the reason behind your use of marijuana? Tell me about the frequency and amount of use.
20. About your HIV status, how have you been managing your diagnosis? Have you been taking your prescribed medication (Biktarvy) consistently as directed? What is your plan for checking your viral load since it’s been six months since you last checked?
21. Are you sexually active? If so, do you engage in safe sexual practices, such as using condoms, to prevent the transmission of HIV or other sexually transmitted infections?
22. How has your new gender identity or transition been received by your family and among your peers?
23. Do you feel supported and accepted in your current living situation? What other support systems do you have?
24. How has being unemployed and moving back with your family impacted your overall well-being, mental health, and ability to access healthcare?

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

Crissman, H. P., Stroumsa, D., Kobernik, E. K., & Berger, M. B. (2019). Gender and Frequent Mental Distress: Comparing Transgender and Non-Transgender Individuals’ Self-Rated Mental Health. Journal of Women’s Health (2002), 28(2), 143–151. https://doi.org/10.1089/jwh.2018.7411Links to an external site.

Kelley J. (2021). Stigma and Human Rights: Transgender Discrimination and Its Influence on Patient Health. Professional case management, 26(6), 298–303. https://doi.org/10.1097/NCM.0000000000000506Links to an external site.

McAuliffe, M., Baker, D., & D’Aoust, R. (2023). Improving healthcare quality for transgender patients in the perioperative setting: The patient’s perspective. Journal of perioperative practice, 33(6), 164–170. https://doi.org/10.1177/17504589221133937Links to an external site.

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Exam: Week 6 Midterm Exam

This exam is a test of your knowledge in preparation for your certification exam. No outside resources, including books, notes, websites, or any other type of resource, are to be used to complete this exam. You are expected to comply with Walden University’s Code of Conduct.

This exam will be on topics covered in weeks 1, 2, 3, 4, 5, and 6. Prior to starting the exam, you should review all of your materials. This exam is timed with a limit of 2 hours for completion. When time is up, your exam will automatically submit.

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Submit your Midterm Exam.

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Week 6: Assessment of the Abdomen and Gastrointestinal System

On your way home from dinner, you start experiencing sharp pains in your abdomen. You ate seafood—could you have food poisoning? What else might be causing your pain? Appendicitis? Should you head to the emergency room, or should you wait and see how you feel in the morning?

Numerous ailments can affect the GI system and the abdomen. Because the organs are so close, it can be difficult to conduct an accurate assessment. Also, pain in another area of the body can affect the GI system. For example, patients with chronic migraines often report nausea.

This week, you will explore how to assess the abdomen and gastrointestinal system.

Learning Objectives

Students will:

• Evaluate abnormal abdomen and gastrointestinal findings
• Apply concepts, theories, and principles relating to health assessment techniques and diagnoses for the abdomen and gastrointestinal system
• Analyze chest X-Ray and abdominal X-Ray imaging
• Identify concepts, theories, and principles related to advanced health assessment

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.

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• 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.