Advanced Practice Nursing Procedures Discussion Paper
Assessing the Abdomen: Analysis
Analysis of the Subjective Portion and Additional Information
The client provided subjective data during the clinical assessment. Upon visiting the emergency department, L.Z reports pain in his stomach that has persisted for the last two days. The client describes the pain as intermittent epigastric abdominal, which radiates toward his back. He reports that PPI given at the local Urgent Care was not relieving the abdominal pain. The client reports an increase in the severity of the pain a few hours ago. The client reports vomiting after lunch, resulting in the current ED visit. L. Z denies diarrhea, fever, or other symptoms attributed to his abdominal pain. Advanced Practice Nursing Procedures Discussion Paper
Nonetheless, additional subjective data should be documented to enable the healthcare provider to make the most appropriate diagnosis and develop an effective treatment plan. First, the rating of the client’s pain should be documented. According to Vuille et al. (2018), the pain relief strategy implemented in the emergency department depends on the intensity and duration of the pain. Thus, pain rating will help the clinician determine the most effective pain management intervention. Additionally, the character of the pain of the client’s abdominal pain should be documented. For instance, the pain can be described as sudden and sharp. Furthermore, the healthcare providers should include aggravating and alleviating factors, which would guide in determining the cause of the pain. Changes in feeding patterns should also be included in the client’s subjective data. Lastly, the clinician should document the characteristics of recent stool. For instance, the client should specify if his recent stool is pale yellow to help the healthcare professional in determining the cause of the stomach pain.
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Analysis of the Objective Portion and Additional Information
The client’s objective data was collected through physical examination and diagnostics. An examination of the abdomen revealed tenderness in the epigastric region with guarding. However, no mass or rebound was detected on the abdomen on examination. Additionally, US and CTA were ordered to confirm physical examination findings. However, additional objective data is required to help the healthcare provider establish the cause of the abdominal pain. The healthcare provider should document the client’s appearance during the clinical assessment. For instance, the client’s appearance could be described as pale. The shape of his abdomen such as abdominal distension should also be included in the objective data. Advanced Practice Nursing Procedures Discussion Paper
Does the Subjective and Objective information Support the Client’s Assessment?
The client’s assessment is supported by the subjective and objective. His current assessment includes Abdominal Aortic Aneurysm (AAA), perforated Ulcer, and pancreatitis. These conditions are characterized by various abdominal symptoms, including pain, nausea, vomiting, and diarrhea. During the clinical interview, the client reports abdominal pain, which radiates toward his back and accompanied by vomiting. Moreover, an examination of the abdomen revealed tenderness in the epigastric region with guarding.
Recommended Diagnostic Tests that would be appropriate for this Client
Various diagnostic tests are recommended to guide the healthcare provider in making an appropriate diagnosis. First, a complete blood count (CBC) should be ordered to detect the presence of potential infection. According to Bai et al (2020), CBC is an effective diagnostic test for disease-causing microorganisms in the blood. Secondly, a liver enzyme test should be performed to establish if his liver is functioning well. Another recommended test is a urinalysis, which should be conducted to check the presence of bacteria or blood in the urine. Furthermore, tests for amylase and lipase levels should be ordered to detect potential pancreatic infection. The clinician should also order an abdominal X-ray to enable him to assess the entire GI tract. Lastly, abdominal ultrasound should be ordered to enable the clinician to establish the cause of the stomach pain by reviewing the images. Advanced Practice Nursing Procedures Discussion Paper
Stand Concerning the Current Diagnosis and Potential Differential Diagnosis
I would reject the client’s current diagnosis, which is Abdominal Aortic Aneurysm AAA. The client could only qualify for this diagnosis following further testing to confirm AAA. Additionally, AAA is ruled out as the client’s primary pain since his abdominal pain is not sudden and persistent. On the contrary, I consider acute pancreatitis as the client’s primary diagnosis. Acute pancreatitis is characterized by upper abdominal pain that radiates toward the back; tenderness on the abdomen on touch; fever, rapid pulse, nausea, and vomiting (Kataria et al., 2020). The client qualifies for this diagnosis since he reports abdominal pain, which radiates toward his back and is accompanied by vomiting. His abdomen is also tender to the touch.
However, potential differential diagnoses for this client should be considered. The first differential diagnosis is gastritis. This condition is characterized by a burning ache or pain in the upper abdomen, nausea and vomiting, and feeling full after eating (Li et al., 2020). The client reports abdominal pain accompanied by vomiting, qualifying for this diagnosis. However, gastritis is ruled out since the client does not report feeling full after eating. The second differential diagnosis is ulcer perforation. This condition is characterized by severe and sudden upper abdominal pain that spread to the shoulder or back; nausea or vomiting; feeling full or lack of appetite; and feeling bloated or swollen belly (Yamamoto et al., 2018). The client reports abdominal pain accompanied by vomiting, qualifying for this diagnosis. However, ulcer perforation is ruled out since the client does not report feeling bloated or swollen belly. Advanced Practice Nursing Procedures Discussion Paper
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 Advanced Practice Nursing Procedures Discussion Paper
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. Advanced Practice Nursing Procedures Discussion Paper
For this week’s assignment you will analyze a SOAP note and complete your assignment based on the documentation provided below. The assignment this week should be completed in the format of a NARRATIVE PAPER to better explain your analysis.
Below is the documentation you will use for your first assignment:
ABDOMINAL ASSESSMENT
- Subjective:
- CC: “My stomach has been hurting for the past two days.”
- HPI: LZ, 65 y/o AA male, presents to the emergency department with a two days history of intermittent epigastric abdominal pain that radiates into his back. He went to the local Urgent Care where was given PPI’s with no relief. At this time, the patient reports that the pain has been increasing in severity over the past few hours; he vomited after lunch, which led his to go to the ED at this time. He has not experienced fever, diarrhea, or other symptoms associated with his abdominal pain.
- PMH: HTN
- Medications: Metoprolol 50mg
- Allergies: NKDA
- FH: HTN, Gerd, Hyperlipidemia
- Social Hx: ETOH, smoking for 20 years but quit both 2 years ago, divorced for 5 years, 3 children, 2 males, 1 female
- Objective:
- VS: Temp 98.2; BP 91/60; RR 16; P 76; HT 6’10”; WT 262lb
- Heart: RRR, no murmurs
- Lungs: CTA, chest wall symmetrical
- Skin: Intact without lesions, no urticaria Advanced Practice Nursing Procedures Discussion Paper
- Abd: abdomen is tender in the epigastric area with guarding but without mass or rebound.
- Diagnostics: US and CTA
- Assessment:
- Abdominal Aortic Aneurysm (AAA)
- Perforated Ulcer
- Pancreatitis
PLAN: This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.
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 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.
- Chapter 18, “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. Advanced Practice Nursing Procedures Discussion Paper - Chapter 3, “Abdominal PainDownload 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”Download 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”Download 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”Download 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. Advanced Practice Nursing Procedures Discussion Paper - Chapter 115, “X-Ray Interpretation of Abdomen”Download “X-Ray Interpretation of Abdomen”(pp. 514–520)
Note: Download this Student Checklist and Abdomen Key Points to use during your practice abdominal examination.
RUBRIC
NURS_6512_Week_6_Assignment_1_Rubric
| NURS_6512_Week_6_Assignment_1_Rubric | ||||||
| Criteria | Ratings | Pts | ||||
| This criterion is linked to a Learning OutcomeWith 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. |
|
12 pts | ||||
| This criterion is linked to a Learning OutcomeAnalyze the objective portion of the note. List additional information that should be included in the documentation. |
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12 pts | ||||
| This criterion is linked to a Learning OutcomeIs the assessment supported by the subjective and objective information? Why or why not? |
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16 pts | ||||
| This criterion is linked to a Learning OutcomeWhat diagnostic tests would be appropriate for this case, and how would the results be used to make a diagnosis? Advanced Practice Nursing Procedures Discussion Paper |
|
20 pts | ||||
| This criterion is linked to a Learning Outcome· 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. |
|
25 pts | ||||
| This criterion is linked to a Learning OutcomeWritten 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. |
|
5 pts | ||||
| This criterion is linked to a Learning OutcomeWritten Expression and Formatting – English writing standards: Correct grammar, mechanics, and proper punctuation |
|
5 pts | ||||
| This criterion is linked to a Learning OutcomeWritten 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. |
|
5 pts | ||||
| Total Points: 100 | ||||||