Assignment Advanced health assessment.
Assignment Advanced health assessment.
Assignment Advanced health assessment-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 1: Lab Assignment: Assessing the Abdomen
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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. Assignment: Advanced health assessment
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. Assignment Advanced health assessment
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. Assignment: Advanced health assessment
To Prepare for Assignment Advanced health assessment
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- Assignment Advanced health assessment
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.
Assignment 2: Lab Assignment 2 (Optional) Practice Assessment: Abdominal Examination
The causes of abdominal pain can be extremely varied due to the sheer number of structures, organs, and functions within the abdomen. If abdominal pain is caused by a life-threatening condition, then swift and accurate assessment is essential. Assignment Advanced health assessment
In preparation for the Comprehensive (Head-to-Toe) Physical Assessment due in Week 9, it is recommended that you practice performing an abdominal examination this week. Assignment: Advanced health assessment
Note: This is an optional practice physical assessment.
To Prepare for Assignment: Advanced health assessment
- Arrange an appropriate time and setting with a volunteer “patient” to perform an abdominal examination.
- Download and review Adult Examination Checklist: Guide for Abdominal Assessment, provided in this week’s Learning Resources, as well as review the Seidel’s Guide to Physical Examinationonline media.
Optional Practice Assessment- Assignment Advanced health assessment
- Perform the abdominal examination. Be sure to cover all of the areas listed in the checklist and to use the equipment appropriately. Assignment Advanced health assessment
What’s Coming Up in Week 7?
Photo Credit: [BrianAJackson]/[iStock / Getty Images Plus]/Getty Images
Next week, you will explore how to assess the heart, lungs, and peripheral vascular system as you complete your Discussion.
Week 7 Required Media
Photo Credit: [fergregory]/[iStock / Getty Images Plus]/Getty Images
Next week, you will need to view several videos and animations in the Seidel’s Guide to Physical Examination as well as other media, as required, prior to completing your Discussion. There are several videos of various lengths. Please plan ahead to ensure you have time to view these media programs to complete your Discussion on time. Assignment Advanced health assessment
Next Week
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. Assignment Advanced health assessment
This week, you will explore how to assess the abdomen and gastrointestinal system.
Learning Objectives for Assignment: Advanced health assessment
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
- Identify concepts, theories, and principles related to advanced health assessment
Learning Resources for Assignment: Advanced health assessment
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. Assignment Advanced health assessment
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.
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.