Lab Assignment Assessing the Abdomen
A male went to the emergency room for severe midepigastric abdominal pain. He was diagnosed with AAA ; however, as a precaution, the doctor ordered a CTA scan.
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
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
- 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.
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.
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.
| Criteria | Ratings | Pts | ||||
|---|---|---|---|---|---|---|
With regard to the SOAP note case study provided, address the following: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 or accept the current diagnosis? Why or why not?· Identify three possible conditions that may be considered as a differenial diagnosis for this patient. Explain your reasoning using at least three different references from current evidence-based literature. | ||||||
Written Expression and Formatting – Paragraph Development and Organization: Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused–neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria. | ||||||
Written Expression and Formatting – English writing standards: Correct grammar, mechanics, and proper punctuation | ||||||
Written Expression and Formatting – The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, running heads, parenthetical/in-text citations, and reference list. | ||||||
Total Points: 100 | ||||||
Expert Answer and Explanation
Abdominal Assessment
Nursing assessment is the process of collecting objective, subjective, and health history data of a patient to determine the disease ailing the client. The process includes recognizing both normal and abnormal psychophysiology. Nursing assessment is done for various purposes.
Ball, Dains, Flynn, Solomon & Stewart (2019) argue that nursing assessment is often done by nurses to identify the patients’ caring needs and health problems. Another significance of nursing assessment is that it used to design care plans and treatment protocols. The purpose of this assignment is to evaluate the Episodic Note case study provided and answering the questions below.
Additional Subjective Data to be included in the Documentation
The charge nurses who recorded the soap note case provided included many information in the subjective data portion. However, there are some elements missing in the portion to make it more unique. The first data that should be added is the race of the patient. The second data is the review of symptoms. Review of systems can help nurses identify abnormalities in the systems (Dains, Baumann & Scheibel, 2019). The third information that should be added in the subjective portion is the patient’s immunization history. Lastly, information about the patient’s hobbies and daily activities should be included in the portion.
Additional Objective Data to be included in the Documentation
The charge nurse also included almost all the data in the objective portion of the soap note but some information is missing. One such data is the patient’s general appearance. When discussing general appearance, information about the patient’s orientation, alertness, and ability to answer questions should be included (Ball et al., 2019). The last data to be included in the objective portion is the diagnostic tests and results. Diagnostic results are vital because they can help a nurse make accurate and informed decisions when recommending treatments and plan.
Justification of the Assessment
The charge nurse assessed that the patient in the soap case study might have left lower quadrant pain or gastroenteritis. In my opinion, these diagnoses were supported by both objective and subjective data. In the subjective portion, the patient complained of diarrhea, stomach pain, and nausea.
These symptoms are among the signs of either left lower quadrant pain or gastroenteritis (Dains et al., 2019). The information in the physical exam was also used to support the diagnosis. The physical exam found pos pain in the LLQ, soft abdomen, and hyperactive bowel sounds which are signs of the two diseases in the diagnosis.
Appropriate Diagnostic Tests for the Case and How they can be used to make Diagnosis
A doctor can order two diagnostic tests for the soap note case assigned. The first test is the blood test. Blood test can be used to identify the infection in the body. Dains et al. (2019) note that to determine the exact type of the infection ailing the patient, the laboratory technician will perform sensitivity and culture test. The blood test can show whether the patient has bacterial, fungal, or viral infection. The second test is urinalysis. Urinalysis will be used to determine whether the patient has a urinary tract infection. This test can be ordered by the doctor because UTI can also cause abdominal or stomach pain and cramp.
Diagnoses
I would not reject the current the current diagnosis because patients with both left lower quadrant pain and gastroenteritis can experience nausea, abdominal pain, stomach pain, and diarrhea as highlighted by the patient in subjective portion of the soap note.
I would also accept the current diagnosis because it has been supported by objective data. When conducting physical assessment, the charge nurse found that the patient had pos pain in the LLQ, soft abdomen, and hyperactive bowel sounds, which are some of the symptoms of the diseases in the diagnosis. Apart from the two diseases, the following are other conditions that can be included in the diagnosis.
The first disease is Ulcerative Colitis. Ulcerative Colitis is a disease that causes sores and inflammation in the digestive tract. The symptoms of the disease include rectal pain, abdominal pain and cramping, and diarrhea (Colombel et al., 2017). The patient complained of diarrhea, abdominal pain, and cramping, and that is why the disease has been included in the diagnosis.
The second disease is Crohn’s disease. This disease causes inflation of digestive tract, a situation that leads to abdominal pain, and that is why it has been included in the diagnosis (Rosen et al., 2017). The third disease is urinary tract infection site not specified. UTI site not specified often affects the urinary tract system organs, and this can lead to adnominal pain and cramping (Clouse, 2018).
Conclusion
Analysis of the soap case study assigned for this assignment showed that there are some information missing in both subjective and objective portions of the soap. The data include the patient’s race, review of symptoms, immunization history, general appearance, and diagnostic tests and results. Analysis has also found that the diagnosis was supported by both subjective and objective data. The tests that can be used to confirm the diagnosis include blood test and urinalysis. Other diseases that can be included in the diagnosis are UTI site not specified, Ulcerative Colitis, and Crohn’s disease.
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.
Clouse, M. K. (2018). Evidence-driven Diagnosis and Treatment of Acute Urinary Tract Infections in Long-term Care. https://repository.belmont.edu/dnpscholarlyprojects/9/
Colombel, J. F., Sands, B. E., Rutgeerts, P., Sandborn, W., Danese, S., D’Haens, G., … & Parikh, A. (2017). The safety of vedolizumab for ulcerative colitis and Crohn’s disease. Gut, 66(5), 839-851. http://dx.doi.org/10.1136/gutjnl-2015-311079
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.
Rosen, M. J., Karns, R., Vallance, J. E., Bezold, R., Waddell, A., Collins, M. H., … & Baker, S. S. (2017). Mucosal expression of type 2 and type 17 immune response genes distinguishes ulcerative colitis from colon-only Crohn’s disease in treatment-naive pediatric patients. Gastroenterology, 152(6), 1345-1357. https://doi.org/10.1053/j.gastro.2017.01.016
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