Assessment of the Abdomen and Gastrointestinal System

Assessment of the Abdomen and Gastrointestinal System

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NURS 6512 Week 6: Assessment of the Abdomen and Gastrointestinal System

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?

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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. Assessment of the Abdomen and Gastrointestinal System

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

Learning Objectives – Week 6: Assessment of the Abdomen and Gastrointestinal System
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

ASSIGNMENT 1: LAB ASSIGNMENT, ASSESSING THE ABDOMEN

Week 6 – The Episodic note case study: Abdominal Assessment

ABDOMINAL ASSESSMENT

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 PPIâ€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 Assessment of the Abdomen and Gastrointestinal System

Objective:

VS: Temp 98.2; BP 91/60; RR 16; P 76; HT 6â€10”; WT 262lbs
Heart: RRR, no murmurs
Lungs: CTA, chest wall symmetrical
Skin: Intact without lesions, no urticaria
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.

With regard to the Episodic note case study provided:
Review this weekâ€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 patientâ€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 Assessment of the Abdomen and Gastrointestinal System
(In the past some students have listed each question that needs to be answered and then wrote their narrative under each question). This is easier for some students.

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.

DO NOT rewrite a SOAP note. Tell me whats wrong with the Episodic SOAP Note, by responding to the statements/questions above.

Read the SOAP note for Abdominal Assessment, do this in paragraph form.

Use subheadings for the 5 Statements/questions. These are from the Rubric.

Rubric Detail

Select Grid View or List View to change the rubricâ€s layout.

Content
Name: NURS_6512_Week_6_Assignment1_Rubric
Excellent Good Fair Poor
Quality of Work Submitted:
The extent of which work meets the assigned criteria and work reflects graduate level critical and analytic thinking.
Points Range: 27 (27%) – 30 (30%)
Assignment exceeds expectations. All topics are addressed with a minimum of 75% containing exceptional breadth and depth about each of the assignment topics.
Points Range: 24 (24%) – 26 (26%)
Assignment meets expectations. All topics are addressed with a minimum of 50% containing good breadth and depth about each of the assignment topics.
Points Range: 21 (21%) – 23 (23%)
Assignment meets most of the expectations. One required topic is either not addressed or inadequately addressed.
Points Range: 0 (0%)– 20 (20%) Assessment of the Abdomen and Gastrointestinal System
Assignment superficially meets some of the expectations. Two or more required topics are either not addressed or inadequately addressed.
Assimilation and Synthesis of Ideas:
The extent to which the work reflects the studentâ€s ability to:Understand and interpret the assignmentâ€s key concepts.
Points Range: 27 (27%) – 30 (30%)
Demonstrates the ability to critically appraise and intellectually explore key concepts.
Points Range: 24 (24%) – 26 (26%)
Demonstrates a clear understanding of key concepts.
Points Range: 21 (21%) – 23 (23%)
Shows some degree of understanding of key concepts.
Points Range: 0 (0%)– 20 (20%)
Shows a lack of understanding of key concepts, deviates from topics.
Assimilation and Synthesis of Ideas:
The extent to which the work reflects the studentâ€s ability to:Apply and integrate material in course resources (i.e. video, required readings, and textbook) and credible outside resources.
NURS 6512 Week 6: Assessment of the Abdomen and Gastrointestinal System

Points Range: 18 (18%) – 20 (20%)
Demonstrates and applies exceptional support of major points and integrates 2 or more credible outside sources, in addition to 2-3 course resources to support point of view. Assessment of the Abdomen and Gastrointestinal System
Points Range: 16 (16%) – 17 (17%)
Integrates specific information from 1 credible outside resource and 2-3 course resources to support major points and point of view.
Points Range: 14 (14%) – 15 (15%)
Minimally includes and integrates specific information from 2-3 resources to support major points and point of view.
Points Range: 0 (0%)– 13 (13%)
Includes and integrates specific information from 0 to 1 resource to support major points and point of view.
Written Expression and FormattingParagraph/Sentence Structure: Paragraphs make clear points that support well developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are clearly structured and carefully focused–neither long and rambling nor short and lacking substance.
Points Range: 9 (9%) – 10 (10%)
Paragraphs/Sentences follow writing standards for structure, flow, continuity and clarity
Points Range: 8 (8%)– 8 (8%)
Paragraphs/sentences follow writing standards for structure, flow, continuity and clarity 80% of the time. Assessment of the Abdomen and Gastrointestinal System
Points Range: 7 (7%)– 7 (7%)
Paragraphs/sentences follow writing standards for structure, flow, continuity and clarity 60%- 79% of the time.
Points Range: 0 (0%)– 6 (6%)
Paragraphs/sentences follow writing standards for structure, flow, continuity and clarity < 60% of the time.
Written Expression and FormattingEnglish writing standards: Correct grammar, mechanics, and proper punctuation.
Points Range: 5 (5%) – 5 (5%)
Uses correct grammar, spelling, and punctuation with no errors.
Points Range: 3 (3%)– 4 (4%)
Contains a few (1-2) grammar, spelling, and punctuation errors.
Points Range: 2 (2%)– 2 (2%)
Contains several (3-4) grammar, spelling, and punctuation errors.
Points Range: 0 (0%)– 1 (1%)
Contains many (≥ 5) grammar, spelling, and punctuation errors that interfere with the readerâ€s understanding.
Written Expression and FormattingThe assignment follows parenthetical/in-text citations, and at least 3 evidenced based references are listed.

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Points Range: 5 (5%) – 5 (5%)
Contains parenthetical/in-text citations and at least 3 evidenced based references are listed. Assessment of the Abdomen and Gastrointestinal System
Points Range: 3 (3%)– 4 (4%)
Contains parenthetical/in-text citations and at least 2 evidenced based references are listed
Points Range: 2 (2%)– 2 (2%)
Contains parenthetical/in-text citations and at least 1 evidenced based reference is listed
Points Range: 0 (0%)– 1 (1%)
Contains no parenthetical/in-text citations and 0 evidenced based references listed.
Total Points: 100 Assessment of the Abdomen and Gastrointestinal System