Assignment 1: Lab Assignment: Assessing the Stomach
Please observe this assignment is due week 6. Please consult with your useful resource listing in addition to your grading rubrics and examine information for week 6. On this Lab Assignment, you’ll analyze an Episodic observe case examine that describes irregular findings in sufferers seen in a medical setting. You’ll think about what historical past ought to be collected from the sufferers in addition to which bodily exams and diagnostic exams ought to be performed. Additionally, you will formulate a differential analysis with a number of potential circumstances. Please use your Useful resource listing and grading rubric as a information. Please attain out to me when you’ve got any questions relating to this assignment
ABDOMINAL ASSESSMENT
Subjective:
CC: “My abdomen hurts, I’ve diarrhea and nothing appears to Help.”
HPI: JR, 47 yo WM, complains of getting generalized stomach ache that began three days in the past. He has not taken any medicines as a result of he didn’t know what to take. He states the ache is a 5/10 immediately however has been as a lot as 9/10 when it first began. He has been in a position to eat, with some nausea afterwards.
PMH: HTN, Diabetes, hx of GI bleed four years in the past
Medicines: Lisinopril 10mg, Amlodipine 5 mg, Metformin 1000mg, Lantus 10 models qhs
Allergy symptoms: NKDA
FH: No hx of colon most cancers, Father hx DMT2, HTN, Mom hx HTN, Hyperlipidemia, GERD
Social: Denies tobacco use; occasional etoh, married, three kids (1 lady, 2 boys)
Goal:
VS: Temp 99.eight; BP 160/86; RR 16; P 92; HT 5’10”; WT 248lbs
Coronary heart: RRR, no murmurs
Lungs: CTA, chest wall symmetrical
Pores and skin: Intact with out lesions, no urticaria
Abd: delicate, hyperactive bowel sounds, pos ache within the LLQ
Diagnostics: None
Assessment:
Left decrease quadrant ache
Gastroenteritis
PLAN: This part just isn’t required for the assignments on this course (NURS 6512) however can be required for future programs.
To Put together
Assessment the Episodic observe case examine your teacher offers you for this week’s Assignment. Please see the “Course Bulletins” part of the classroom in your Episodic observe case examine.
With regard to the Episodic observe case examine supplied:
Assessment this week’s Studying Sources, and think about the insights they supply in regards to the case examine.
Contemplate what historical past could be essential to gather from the affected person within the case examine.
Contemplate what bodily exams and diagnostic exams could be applicable to assemble extra details about the affected person’s situation. How would the outcomes be used to make a analysis?
Establish no less than 5 potential circumstances that could be thought-about in a differential analysis for the affected person.
The Assignment
Analyze the subjective portion of the observe. Checklist further data that ought to be included within the documentation.
Analyze the target portion of the observe. Checklist further data that ought to be included within the documentation.
Is the Assessment supported by the subjective and goal data? Why or why not?
What diagnostic exams could be applicable for this case, and the way would the outcomes be used to make a analysis?
Would you reject/settle for the present analysis? Why or why not? Establish three potential circumstances that could be thought-about as a differential analysis for this affected person. Clarify your reasoning utilizing no less than three completely different references from present evidence-based literature.
Rubric Element
Choose Grid View or Checklist View to alter the rubric’s format.
Title: NURS_6512_Week_6_Assignment_1_Rubric
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Grid View
Checklist View
Wonderful Good Honest Poor
With regard to the SOAP observe case examine supplied, deal with the next:
Analyze the subjective portion of the observe. Checklist further data that ought to be included within the documentation.
10 (10%) – 12 (12%)
The response clearly, precisely, and completely analyzes the subjective portion of the SOAP observe and lists detailed further data to be included within the documentation.
7 (7%) – 9 (9%)
The response precisely analyzes the subjective portion of the SOAP observe and lists further data to be included within the documentation.
four (four%) – 6 (6%)
The response vaguely and/or with some inaccuracy analyzes the subjective portion of the SOAP observe and vaguely and/or with some inaccuracy lists further data to be included within the documentation.
zero (zero%) – three (three%)
The response inaccurately analyzes or is lacking Assessment of the subjective portion of the SOAP observe, with inaccurate and/or lacking further data included within the documentation.
Analyze the target portion of the observe. Checklist further data that ought to be included within the documentation.
10 (10%) – 12 (12%)
The response clearly, precisely, and completely analyzes the target portion of the SOAP observe and lists detailed further data to be included within the documentation.
7 (7%) – 9 (9%)
The response precisely analyzes the target portion of the SOAP observe and lists further data to be included within the documentation.
four (four%) – 6 (6%)
The response vaguely and/or with some inaccuracy analyzes the target portion of the SOAP observe and vaguely and/or inaccurately lists further data to be included within the documentation.
zero (zero%) – three (three%)
The response inaccurately analyzes or is lacking Assessment of the target portion of the SOAP observe, with inaccurate and/or lacking further data included within the documentation.
Is the Assessment supported by the subjective and goal data? Why or why not?
14 (14%) – 16 (16%)
The response clearly and precisely identifies whether or not or not the Assessment is supported by the subjective and/or goal data, with a radical and detailed clarification.
11 (11%) – 13 (13%)
The response precisely identifies whether or not or not the Assessment is supported by the subjective and/or goal data, with an evidence.
eight (eight%) – 10 (10%)
The response vaguely and/or inaccurately identifies whether or not or not the Assessment is supported by the subjective and/or goal data, with a imprecise clarification.
zero (zero%) – 7 (7%)
The response inaccurately identifies whether or not or not the Assessment is supported by the subjective and/or goal data, with an inaccurate or lacking clarification.
What diagnostic exams could be applicable for this case, and the way would the outcomes be used to make a analysis?
18 (18%) – 20 (20%)
The response completely and precisely describes applicable diagnostic exams for the case and explains clearly, completely, and precisely how the take a look at outcomes could be used to make a analysis.
15 (15%) – 17 (17%)
The response precisely describes applicable diagnostic exams for the case and explains clearly and precisely how the take a look at outcomes could be used to make a analysis.
12 (12%) – 14 (14%)
The response vaguely and/or with some inaccuracy describes applicable diagnostic exams for the case and vaguely and/or with some inaccuracy explains how the take a look at outcomes could be used to make a analysis.
zero (zero%) – 11 (11%)
The response inaccurately describes applicable diagnostic exams for the case, with an inaccurate or lacking clarification of how the take a look at outcomes could be used to make a analysis.
· Would you reject or settle for the present analysis? Why or why not?
· Establish three potential circumstances that could be thought-about as a differenial analysis for this affected person. Clarify your reasoning utilizing no less than three completely different references from present evidence-based literature.
23 (23%) – 25 (25%)
The response states clearly whether or not to simply accept or reject the present analysis, with a radical, correct, and detailed clarification of sound reasoning. The response clearly, completely, and precisely identifies three circumstances as a differential analysis, with reasoning that’s defined clearly, precisely, and completely utilizing no less than three completely different references from present evidence-based literature.
20 (20%) – 22 (22%)
The response states whether or not to simply accept or reject the present analysis, with an correct clarification of sound reasoning. The response precisely identifies three circumstances as a differential analysis, with reasoning that’s defined precisely utilizing three completely different references from present evidence-based literature.
17 (17%) – 19 (19%)
The response states whether or not to simply accept or reject the present analysis, with a imprecise clarification of the reasoning. The response identifies two or three circumstances as a differential analysis, with reasoning that’s defined vaguely and/or inaccurately utilizing three references from present evidence-based literature.
zero (zero%) – 16 (16%)
The response inaccurately or is lacking a press release of whether or not to simply accept or reject the present analysis, with an evidence that’s inaccurate and/or lacking. The response identifies two or fewer circumstances as a differential analysis, with reasoning that’s lacking or defined inaccurately utilizing three or fewer references from present evidence-based literature.
Written Expression and Formatting – Paragraph Improvement and Group:
Paragraphs clarify factors that help well-developed concepts, circulate logically, and exhibit continuity of concepts. Sentences are fastidiously focused–neither lengthy and rambling nor quick and missing substance. A transparent and complete goal assertion and introduction are supplied that delineate all required standards.
5 (5%) – 5 (5%)
Paragraphs and sentences observe writing requirements for circulate, continuity, and readability. A transparent and complete goal assertion, introduction, and conclusion are supplied that delineate all required standards.
four (four%) – four (four%)
Paragraphs and sentences observe writing requirements for circulate, continuity, and readability 80% of the time. Goal, introduction, and conclusion of the assignment are acknowledged, but are temporary and never descriptive.
three (three%) – three (three%)
Paragraphs and sentences observe writing requirements for circulate, continuity, and readability 60%–79% of the time. Goal, introduction, and conclusion of the assignment are imprecise or off matter.
zero (zero%) – 2 (2%)
Paragraphs and sentences observe writing requirements for circulate, continuity, and readability < 60% of the time. No goal assertion, introduction, or conclusion had been supplied.
Written Expression and Formatting – English writing requirements:
Right grammar, mechanics, and correct punctuation
5 (5%) – 5 (5%)
Makes use of right grammar, spelling, and punctuation with no errors.
four (four%) – four (four%)
Accommodates a number of (1 or 2) grammar, spelling, and punctuation errors.
three (three%) – three (three%)
Accommodates a number of (three or four) grammar, spelling, and punctuation errors.
zero (zero%) – 2 (2%)
Accommodates many (≥ 5) grammar, spelling, and punctuation errors that intrude with the reader’s understanding.
Written Expression and Formatting – The paper follows right APA format for title web page, headings, font, spacing, margins, indentations, web page numbers, operating heads, parenthetical/in-text citations, and reference listing.
5 (5%) – 5 (5%)
Makes use of right APA format with no errors.
four (four%) – four (four%)
Accommodates a number of (1 or 2) APA format errors.
three (three%) – three (three%)
Accommodates a number of (three or four) APA format errors.
zero (zero%) – 2 (2%)
Accommodates many (≥ 5) APA format errors.
Complete Factors: 100
Title: NURS_6512_Week_6_Assignment_1_Rubric
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