directions:
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 in the present day 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
Drugs: Lisinopril 10mg, Amlodipine 5 mg, Metformin 1000mg, Lantus 10 items qhs
Allergic reactions: 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 youngsters (1 woman, 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 will likely be required for future programs.
Welcome to Week 6. You’ll full an Assessment of the SOAP observe offered. This may be written in narrative or SOAP observe format. Analyze the subjective and goal part of the observe and listing any further data that must be included. Assessment syllabus for extra data to incorporate.
INSTRUCTIONS
Assignment 1: Lab Assignment: Assessing the Stomach
Photograph Credit score: Getty Photos/Hero Photos
A girl went to the emergency room for extreme stomach cramping. She was identified with diverticulitis; nonetheless, as a precaution, the physician ordered a CT scan. The CT scan revealed a development on the pancreas, which turned out to be pancreatic most cancers—the true reason behind the cramping.
Due to a excessive potential for misdiagnosis, figuring out the exact reason behind stomach ache may be time consuming and difficult. By analyzing case research of irregular stomach findings, nurses can put together themselves to higher diagnose situations within the stomach.
On this Lab Assignment, you’ll analyze an Episodic observe case research that describes irregular findings in sufferers seen in a scientific setting. You’ll take into account what historical past must be collected from the sufferers in addition to which bodily exams and diagnostic assessments must be carried out. Additionally, you will formulate a differential analysis with a number of doable situations.
To Put together
Assessment the Episodic observe case research your teacher gives you for this week’s Assignment. Please see the “Course Bulletins” part of the classroom on your Episodic observe case research.
With regard to the Episodic observe case research offered:
Assessment this week’s Studying Sources, and take into account the insights they supply in regards to the case research.
Think about what historical past can be obligatory to gather from the affected person within the case research.
Think about what bodily exams and diagnostic assessments can be acceptable to collect extra details about the affected person’s situation. How would the outcomes be used to make a analysis?
Establish not less than 5 doable situations that could be thought-about in a differential analysis for the affected person.
The Assignment
Analyze the subjective portion of the observe. Listing further data that must be included within the documentation.
Analyze the target portion of the observe. Listing further data that must be included within the documentation.
Is the Assessment supported by the subjective and goal data? Why or why not?
What diagnostic assessments can be acceptable 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 doable situations that could be thought-about as a differential analysis for this affected person. Clarify your reasoning utilizing not less than three completely different references from present evidence-based literature.
Rubric
Title: NURS_6512_Week_6_Assignment_1_Rubric
Grid View
Listing View
Present Descriptions
With regard to the SOAP observe case research offered, deal with the next:
Analyze the subjective portion of the observe. Listing further data that must be included within the documentation.–
Ball: Seidel’s Information to Bodily Examination, eighth Version
Chapter 17: Stomach
Key Factors
This overview discusses examination of the stomach.
• Earlier than the examination, collect the mandatory gear: stethoscope, centimeter ruler, non-stretch tape measure, and marking pen.
To examine the stomach, carry out the next.
• Utilizing tangential lighting, examine the stomach for 4 floor traits.
o First, observe the pores and skin shade. It might fluctuate tremendously however shouldn’t have any jaundice, cyanosis, redness, bruises, or discoloration.
o Second, examine for nodules and different lesions, which shouldn’t be current.
o Third, observe any scars and draw their location, configuration, and relative measurement on an illustration of the stomach.
o Fourth, assess the venous return. Above the umbilicus, venous return must be towards the top. Beneath the umbilicus, it must be towards the toes.
• Subsequent, examine the stomach contour and symmetry.
o The contour is the stomach profile from the rib margin to the pubis. It usually could also be flat, rounded, or scaphoid. The umbilicus must be centrally situated and could also be inverted or could protrude barely.
o Contralateral areas of the stomach must be symmetrical in look and contour and shouldn’t have any distention or bulges.
o To elicit hidden plenty or bulges, have the affected person take a deep breath and maintain it. The stomach ought to stay clean and symmetrical. Subsequent, have the supine affected person increase their head from the desk as you examine the stomach. Be aware any plenty, hernia, or muscle separation.
• With the affected person’s head at relaxation, observe for 3 varieties of stomach motion.
o First, examine for clean, even motion with respiration.
o Second, assess for floor movement from peristalsis. In a skinny affected person, it usually could also be seen. In any other case, it could sign an intestinal obstruction.
o Third, observe any aortic pulsation within the higher midline. Though pulsations could also be seen in a skinny affected person, marked pulsations recommend a dysfunction.
To auscultate the stomach, carry out the next.
• Keep in mind to auscultate earlier than you percuss or palpate as a result of these strategies can alter bowel sounds. Utilizing the diaphragm of a warmed stethoscope, pay attention for bowel sounds and observe their frequency and character.
o Anticipate to listen to clicks and gurgles at a price of 5 to 35 per minute.
o Be aware sudden findings, corresponding to elevated or decreased bowel sounds or high-pitched tinkling sounds.
• Auscultate for 3 further sounds.
o First, use the stethoscope diaphragm to detect high-pitched friction rubs over the liver and spleen.
o Second, use the stethoscope bell to examine for bruits over the aortic, renal, iliac, and femoral arteries.
o Third, use the stethoscope bell to evaluate for a delicate, steady, low-pitched venous hum within the epigastric space and across the umbilicus.
To percuss the stomach, carry out the next.
• Systematically percuss for tone in all stomach quadrants.
o Tympany is heard over the abdomen and intestines.
o Dullness is heard over organs and stable plenty.
• Percuss to estimate the liver span, utilizing three steps.
o First, decide the decrease border of the liver by percussing up from an space of tympany alongside the best midclavicular line. Mark the purpose the place tympany adjustments to dullness, which often happens at or barely beneath the costal margin.
o Second, decide the higher border of the liver by percussing down from an space of resonance alongside the best midclavicular line. Mark the purpose the place resonance adjustments to dullness, which often is within the fifth intercostal house.
o Third, measure the space between the marks. The vertical liver span often ranges from 6 to 12 cm.
• To evaluate liver descent, ask the affected person to take a deep breath and maintain it when you percuss the decrease border once more. With this maneuver, the realm of dullness on the decrease border ought to shift down 2 to three cm.
• Percuss the spleen simply posterior to the midaxillary line on the left aspect, starting in areas of lung resonance and shifting in a number of instructions. You usually could hear a small space of splenic dullness from the sixth to ninth rib. Percuss the bottom intercostal house within the left anterior axillary line earlier than and after the affected person takes a deep breath. Tympany ought to stay on this space.
• Percuss for the gastric air bubble within the left decrease anterior rib cage and left epigastric area. Gastric bubble tympany is decrease in pitch than intestinal tympany.
• With the affected person seated, percuss the kidneys, following two steps.
o First, place the palm of your hand over the best costovertebral angle and strike it with the aspect of the fist of your different hand.
o Second, repeat this motion on the left costovertebral angle. In each areas, the affected person ought to really feel a thud however no ache.
To palpate the stomach, carry out the next.
• Utilizing gentle palpation, systematically assess all quadrants. However first, attempt to chill out the stomach muscle tissues. For instance, place a small pillow below the affected person’s head and barely flexed knees, heat your fingers, take a gradual and delicate strategy, and save any tender areas for final. For gentle palpation, press in not more than 1 cm with the palmar floor of your fingers.
o Anticipate the stomach to really feel clean and delicate.
o Be aware any resistance or tenderness. And look ahead to guarding, which ought to warn you to proceed with warning.
• Utilizing average palpation, systematically assess all quadrants in two methods.
o First, palpate with the palmar floor of your fingers. This may occasionally elicit tenderness that was not produced by gentle palpation.
o Second, palpate with the aspect of your hand all through the respiratory cycle. Because the affected person inhales, you might really feel the liver and spleen bump gently in opposition to your hand.
• Utilizing deep palpation, systematically assess all quadrants with the palmar floor of your fingers. If a affected person’s weight problems or muscular resistance makes deep palpation tough, attempt bimanual palpation with one hand on prime of the opposite. With both method, really feel for the rectus abdominis muscle tissues, aorta, and parts of the colon. Be aware any tenderness.
• If you happen to detect a mass, consider its location, measurement, form, consistency, tenderness, pulsation, mobility, and motion with respiration. To see if the mass is superficial or intraabdominal, palpate because the affected person lifts his or her head off the desk. A superficial mass will stay palpable; an intraabdominal mass won’t.
• Palpate the umbilical ring and periumbilical space. The umbilical ring ought to really feel spherical and common. The world shouldn’t have any bulges, nodules, or granulation.
• Palpate for particular stomach buildings.
o For the liver, press in and really feel for its edge on the proper costal margin because the affected person takes a deep breath. If palpable, the liver ought to really feel agency, clean, even, and nontender.
o For the gallbladder, palpate beneath the liver margin on the lateral border of the rectus abdominus muscle. A wholesome gallbladder just isn’t palpable.
o For the spleen, press in over the left costal margin because the affected person takes a deep breath. The spleen just isn’t often palpable.
o For the kidneys, assess the best and left organs individually, putting one hand on the flank and the opposite hand on the costal margin. Because the affected person inhales deeply, raise the flank and palpate deeply. The proper kidney is extra generally palpable than the left kidney.
o For the aorta, palpate deeply for the aortic pulsation barely left of the midline. If the pulsation is outstanding, attempt to decide its route.
o For the bladder, palpate above the symphysis pubis. If the bladder is distended with urine, it seems like a clean, spherical, tense mass.
To evaluate the stomach additional, carry out the next.
• If you happen to suspect ascites, percuss the supine affected person’s stomach for dullness within the dependent components and tympany within the higher components. Additionally assess for shifting dullness or fluid wave.
• If the affected person stories stomach ache, assess it completely, particularly its high quality and site. When analyzing the stomach, you should definitely watch the affected person’s face for clues to ache. If wanted, assess for rebound tenderness and carry out the iliopsoas muscle and obturator muscle assessments.
• If you happen to suspect a freely movable stomach mass, carry out ballottement.
Title: NURS_6512_Week_6_Assignment_1_Rubric
sources
Chapter 6, “Very important Indicators and Ache Assessment”
This chapter describes the expertise of ache and its causes. The authors additionally describe the method of ache Assessment.
Chapter 18, “Stomach”
On this chapter, the authors summarize the anatomy and physiology of the stomach. The authors additionally clarify the best way to conduct an Assessment of the stomach.
Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Superior well being Assessment and scientific analysis in major care (sixth ed.). St. Louis, MO: Elsevier Mosby.
Credit score Line: Superior Well being Assessment and Scientific Prognosis in Major Care, sixth Version by Dains, J.E., Baumann, L. C., & Scheibel, P. Copyright 2019 by Mosby. Reprinted by permission of Mosby through the Copyright Clearance Middle.
Chapter three, “Stomach Ache”
This chapter outlines the best way to acquire a targeted historical past on stomach ache. That is adopted by what to search for in a bodily examination with a purpose to make an correct analysis.
Chapter 10, “Constipation”
The main target of this chapter is on figuring out the causes of constipation by means of taking a targeted historical past, conducting bodily examinations, and performing laboratory assessments.
Chapter 12, “Diarrhea”
On this chapter, the authors concentrate on diagnosing the reason for diarrhea. The chapter contains inquiries to ask sufferers in regards to the situation, issues to search for in a bodily examination, and urged laboratory or diagnostic research to carry out.
Chapter 29, “Rectal Ache, Itching, and Bleeding”
This chapter focuses on the best way to diagnose rectal bleeding and ache. It features a desk containing doable diagnoses, the accompanying bodily indicators, and urged diagnostic research.
Colyar, M. R. (2015). Superior apply nursing procedures. Philadelphia, PA: F. A. Davis.
Credit score Line: Superior apply nursing procedures, 1st Version by Colyar, M. R. Copyright 2015 by F. A. Davis Firm. Reprinted by permission of F. A. Davis Firm through the Copyright Clearance Middle.
These sections beneath clarify the procedural data wanted to carry out gastrointestinal procedures.
Chapter 107, “X-Ray Interpretation: Chest (pp. 480–487)
Chapter 115, “X-Ray Interpretation of Stomach” (pp. 514–520)
Be aware: Obtain this Pupil Guidelines and Stomach Key Factors to make use of throughout your apply stomach examination.
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NURS 6512 Week 6 Assignment NURS 6512 Week 6 Assignment
Title of the Pupil Institutional Affiliation of the Pupil Course
Title of the professor and the date
NURS 6512 Week 6 Assignment NURS 6512 Week 6 Assignment
Subjective Info that isn’t required
It’s required to acquire additional subjective data as a result of the affected person was unable to adequately categorical his or her ache. The affected person didn’t specify the situation of the stomach ache when she reported it. The discomfort was not described by the affected person, regardless of his makes an attempt to take action. He described the agony as throbbing, acute, taking pictures, and cramping. The affected person didn’t present an in depth account of what occurred when the ache started. He did not go into element in regards to the varieties of meals that trigger the discomfort. He didn’t elaborate on how lengthy the ache lasts or on any aggravating circumstances, corresponding to defecating or belching, that will contribute to it. Sufferers are required to offer an intensive overview of their programs with a purpose to guarantee an intensive Assessment.
System Analysis Via the Eyes of the Beholder
Basic: There was no weight reduction or acquire, nor was there any fever or weariness.
HEENT: There isn’t any imaginative and prescient loss, yellowing of the sclera, or blurring of imaginative and prescient. There are not any listening to points. There will likely be no operating nostril. There was no tonsillitis.
Pores and skin: There are not any sores, itching, or rashes on the pores and skin.
Edema, chest stress, discomfort, or chest ache should not current within the cardiovascular system.
Respiratory: There isn’t any shortness of breath, coughing, or manufacturing of sputum within the system.
Stomach discomfort, nausea, and diarrhea are all signs of gastrointestinal misery. There will likely be no vomiting.
Genitourinary: There are not any urinary points.
Neurological: There have been no complications, seizures, or adjustments in bladder management noticed.
Musculoskeletal: There isn’t any discomfort or stiffness within the muscle tissues.
Hematologic findings: There isn’t any anemia or bruising.
No swollen lymph nodes or splenectomy have been carried out within the lymphatic system.
Psychiatric: There are not any indicators of melancholy or anxiousness.
Endocrinologic: There have been no stories of extreme sweating, polyuria, or dysuria.
Not one of the following allergy symptoms exist: eczema, rhinitis, or bronchial asthma.
Goal Info that isn’t already recognized
An examination of the groin must be carried out as a part of a complete analysis of the affected person. The purpose is to rule out the opportunity of an incarcerated hernia or testicular torsion because the supply of the ache. Tenderness of the flanks is set by percussing the meat on the bone (Jackson & Cruz, 2018). The presence of kidney stones, for instance, may be indicated by flank ache. The vaginal and prostrate areas must be examined by a healthcare supplier to rule out the presence of sexually transmitted diseases. A nurse ought to look at fecal occult or frank blood for indicators of an infection. For instance, the presence of blood could sign the existence of most cancers or the presence of an emergency state of affairs (Jackson & Cruz, 2018). In some circumstances, stomach discomfort could be referred to different organs or sections of the physique, necessitating a bodily examination of the guts, lungs, head, and neck.
Is the present analysis a passable one?
The present analysis doesn’t meet the standards for extra assessments and investigations which might be required. Nonetheless, with a purpose to rule out different possible diseases, the superior nurse practitioner ought to carry out further assessments to substantiate the analysis of gastroenteritis (Dains et al., 2018). Sufferers affected by gastroenteritis, for instance, could have diarrhea, fever, vomiting, hyperactive bowel sounds, and nausea, amongst different signs. A vomiting episode has not been famous by the affected person within the case research. Gastroenteritis is a situation that may resolve by itself.
Checks for Prognosis
Previous to performing diagnostic assessments, it’s vital to acquire a complete medical historical past from the affected person. There isn’t any requirement for laboratory assessments. Sufferers with a chronic fever or blood of their stool or urine, however, could require further testing (Dains et al., 2018). X-rays and CT scans are examples of assessments that could be used to help within the analysis of this situation.
Differential Prognosis is a medical time period that refers back to the technique of figuring out whether or not or not something is mistaken.
Different problems corresponding to irritable bowel syndrome, intestinal blockage, and ureterolithiasis might be indicated by the affected person’s ambiguous signs, which might be indicative of different situations as nicely.
Continual constipation and stomach cramps are signs of irritable bowel syndrome, which is a prevalent sickness characterised by diarrhea, bloating, diarrhea, constipation, and stomach cramping. For the affected person, a gastrointestinal examination in addition to a blood take a look at are required (Brady & Pade, 2018). If the situation just isn’t current, the blood take a look at ends in a unfavorable end result. A complicated nurse practitioner ought to take note of the affected person’s historical past of colorectal most cancers in addition to his or her age. Different considerations embrace whether or not or not the stool accommodates blood and whether or not or not the affected person reveals enchancment between 6 and eight weeks (Brady & Pade, 2018). Proctosigmoidoscopy will likely be carried out because of the issues.
The syndrome occurs in sufferers who’ve had latest gastrointestinal surgical procedure, the aged, and infants, amongst different teams of individuals. Along with adhesions that kind after surgical procedure and colon most cancers in addition to hernias and diverticulitis, there are different blockage causes (Brady & Pade, 2018). Sufferers current with crampy ache that seems out of nowhere. Sufferers complain of nausea and vomiting. The presence of obstruction causes diarrhea, whereas partial obstruction causes diarrhea. When there’s an obstruction, there are hyperactive bowel noises current. When there’s an obstruction, there’s stomach distention current (Reddy & Cappell, 2017). With a purpose to diagnose the situation, a complicated nurse practitioner ought to carry out X-rays, an MRI, or a CT scan.
Ureterolithiasis is a dysfunction that develops when kidney stones lodge within the ureters of the kidneys. Sufferers with the sickness complain of excruciating colicky discomfort which may progress to power agony over a time period. Signs embrace decrease stomach and groin ache in some sufferers (Brady & Pade, 2018). Vomiting, chills, and stomach distention are among the many different indicators and signs. Sufferers may have hematuria and elevated frequency of urination. The analysis includes a urine examination to detect the pH of the urine in addition to an Assessment of the stone composition (Brady & Pade, 2018). A non-contrast-enhanced helical computed tomography CT scan will also be used to make a analysis.
References
Brady, Okay., and Pade, Okay. H. (in press) (2018). An evidence-based strategy to the administration of acute gastroenteritis in pediatric sufferers [digest]. Acute Care in Pediatric Emergency Drugs, vol. 15, no. 2 (supplementary factors and pearls), pp. 1–2.
In J. E. Dains and L. C. Baumann’s article, P. Scheibel describes how they got here to be (2018). On this e-book, you’ll find out about superior well being Assessment and scientific analysis in major care. Elsevier Well being Sciences is a writer of health-related data.
Jackson, P., and Cruz, M. V. (in press) (2018). Analysis and remedy of intestinal blockage. The American Household Doctor, vol. 98, no. 6, pp. 362-367.
S. R. R. Reddy and M. S. Cappell are two of essentially the most well-known scientists on this planet (2017). A scientific research of the scientific presentation, analysis, and remedy of small bowel obstruction was carried out by the researchers. Journal of Gastroenterology and Hepatology, 19(6), 28.
