Assessing the Abdomen: NURS 6512 Week 7 Discussion
Assessing the Abdomen: NURS 6512 Week 7 Discussion
Abdominal Assessment
Abdominal problems have adverse effects on the health and wellbeing of the patients. Nurses are expected to utilize their knowledge and skills in comprehensive history taking and patient assessment to develop accurate diagnoses and treatment plans for their patients. Therefore, this paper is an examination of J.R’s case study. J.R is a 47-year-old client that has come to the hospital with generalized abdominal pain for the last three days and nausea. The purpose of this paper is to examine the additional subjective and objective information to be obtained from the client, whether the case study has subjective and objective data, diagnostic investigations, and decision related to the developed diagnosis.
Analysis of Subjective Portion
Subjective data relates to that obtained from the patient. It focuses on the experiences of the patient with the health problem. Additional subjective information should be obtained from the patient to come up with an accurate diagnosis and treatment plan. One of the subjective data that should be obtained from the client is quantification of the abdominal pain.
Information about the pain rating, severity, character, and relieving, precipitating, and aggravating factors should be obtained. The other aspect of the pain should focus on whether the pain is generalized, radiating to other body parts, or increasing or decreasing in intensity. The pain should also be described in terms of whether it is sudden or gradual.
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Moreover, the nature of diarrhea that the client reports should also be quantified. A focus should be placed on aspects such as the frequency of the diarrhea in a given period to determine if they client is dehydrated or not. The additional information about diarrhea include color of stool, relieving, aggravating, and precipitating factors. The provider should also obtain information about the dietary history of the client. Food poisoning could be a factor to consider in this client’s case. As a result, information about recent dietary habits and perceived hygiene of the foods should be obtained to determine the cause of the problem.
The hygiene status and source of water that the client drinks should be obtained to ascertain whether the problem is a water-borne disease. Since the client has history of gastrointestinal bleeding, it would be necessary to ask about recent changes in color, smell, and texture of the stool prior to the current problems (Jarvis & Eckhardt, 2019). Such information will aid in ruling out causes such as ulcers of the gastrointestinal system.
Analysis of Objective Position
Healthcare providers obtain objective data using methods such as observation, palpation, percussion, and auscultation. The data is important in confirming or validating the subjective data given by the patient. Additional objective data should be obtained from the client. They include the general appearance of the client during the first encounter with the healthcare provider. The healthcare provider should provide a description of the grooming, energy levels, body weight, and if the patient is dehydrated or not. The provider should have also assessed the patient for hydration status and jaundice by checking on skin turgor and sclera for jaundice.
The patient should have also provided comprehensive abdominal assessment to determine whether there is distention, bowel movements, organomegally, distention of veins, and scars. The provider should have also palpated the abdomen for tenderness, rigidity, or any rebound tenderness. The information could have helped rule out causes such as bowel obstruction and organomegally (Jarvis, 2019). The objective data could have facilitated the development of an accurate diagnosis for the client.
Analysis of the Assessment
Objective and subjective data support the assessment of JR. Examples of subjective data that supports the assessment include information about diarrhea, nausea, stomach pains, past medical, medication, allergies, family, and social histories. Examples of objective data include the vitals and heart, lungs, skin, and abdominal findings.
Diagnostic Tests
Stool test is the most appropriate diagnostic investigation for JR. Stool analysis should be performed to determine if the client has an infection or the cause could be due to gastrointestinal bleeding. Blood tests such as complete blood count are also recommended to determine if the client has low hemoglobin level due to bleeding or elevated white blood cell count to indicate infection. Since the client has a history of gastrointestinal bleeding, it would be appropriate to perform abdominal ultrasound to determine the actual cause of the problem (Jarvis & Eckhardt, 2019).
Rejecting/Accepting the Diagnosis
I would accept the current diagnosis. Patients with gastroenteritis experience symptoms similar to those of JR. The symptoms include abdominal cramps, vomiting, nausea, and diarrhea. The infection is short-term, implying symptom resolution over time. JR reports that the pain severity has declined, implying a potential symptom resolution in gastroenteritis. He also complains of diarrhea, abdominal pain, and nausea, hence, the decision to accept the diagnosis (Bányai et al., 2018). The differential diagnoses to be considered include abdominal obstruction, colon cancer, and inflammatory bowel disease.
The above differentials have patients experiencing either nausea, vomiting, diarrhea, or abdominal pains. However, it may not be abdominal obstruction due to the presence of diarrhea and absence of abdominal distention. Diagnostic investigations such as abdominal ultrasound are needed to rule out colon cancer. The patient does not have any predisposition to environmental triggers, hence, ruling out inflammatory bowel disease (Guan, 2019).
Conclusion
Subjective and objective data guide the diagnoses developed for health problems affecting patients. JR is likely to be suffering from gastroenteritis. Additional subjective and objective data is however needed to develop an accurate diagnosis. Diagnostic investigations should be used to develop accurate diagnosis for the patient.
References
Bányai, K., Estes, M. K., Martella, V., & Parashar, U. D. (2018). Viral gastroenteritis. The Lancet, 392(10142), 175–186. https://doi.org/10.1016/S0140-6736(18)31128-0
Guan, Q. (2019). A Comprehensive Review and Update on the Pathogenesis of Inflammatory Bowel Disease. Journal of Immunology Research, 2019, e7247238. https://doi.org/10.1155/2019/7247238
Jarvis, C. (2019). Physical Examination & Health Assessment Access Code. Elsevier Health Sciences.
Jarvis, C., & Eckhardt, A. (2019). Physical Examination and Health Assessment. Elsevier.
The SOAP Note depicts the case of JR, a 47-year-old White male with complaints of generalized abdominal pain and diarrhea. The SOAP note includes the patient’s subjective history, objective portion, and assessment findings. The assessment portion includes Left lower quadrant pain and Gastroenteritis. This paper seeks to analyze the SOAP note, explain appropriate diagnostic tests, and the differential diagnoses for this case.
Subjective Portion
The subjective portion contains the chief complaint, history of present illness (HPI), past medical history (PMH), allergies, family history, and social history. The HPI describes the chief complaint of abdominal pain, including the onset, location, associated symptom, and pain severity. Additional information is needed on the duration of each pain episode, characteristics of the pain, aggravating factors, and relieving factors (Gossman, Lew & Ghassemzadeh, 2020). The HPI should describe if the abdominal pain is sharp, crampy, colicky dull, constant, or radiating. It should also have information on the time of the day when the pain is most severe.
Additional information is needed on diarrhea symptoms; including its onset, frequency, stool characteristics such as consistency, and volume, aggravating factors, and related symptoms such as tenesmus (Gossman et al., 2020). Information on stool characteristics should describe if the stool is mucoid, watery, bloody, greasy, frothy, or foul-smelling and the color of stools. Furthermore, the HPI should provide information on food ingestion history, water exposure, travel history, and predisposing conditions.
The PMH provides information on the patient’s medical history, including chronic illnesses such as hypertension, Diabetes, and GI bleed that occurred four years ago. It should have included additional information on the year of diagnosis of diabetes and hypertension and state if the patient has adequately controlled blood pressure and glucose. Additional information is needed on the frequency that the patient takes Lisinopril, Amlodipine, and Metformin.
The social history provides information on the patient’s tobacco and alcohol use and marital status. However, it should include additional information on his living environment, major hobbies, education status, source of income, health promotion activities, and safety measures taken by the patient (Gossman et al., 2020). The subjective history should have also included the patient’s surgical history, traumatic injuries, and current immunization status (Gossman et al., 2020). Besides, a review of all systems should be included in the subjective portion, identifying symptoms affecting other body systems not mentioned in the HPI.
Objective Portion
The objective portion includes vital signs, anthropometric measurements, and physical exam findings from the assessment of the lungs, heart, skin, and abdomen. However, it should have provided information on the general examination findings. This includes the patient’s general health status, grooming, dressing, mannerism, eye contact, and speech. The focused abdominal assessment should also provide detailed information on the normal and abnormal findings from a comprehensive exam of the abdomen. For example, it should have information on the liver span and location of the spleen from the left coastal margin to determine if there is hepatosplenomegaly. Additionally, it should indicate the presence or absence of palpation findings such as abdominal masses, muscle guarding, muscle spasm, or rebound tenderness.
Assessment Portion
The assessment findings in the SOAP note include Left lower quadrant (LLQ) pain and Gastroenteritis. LLQ is supported by objective findings of pos pain in the LLQ. However, it is not consistent with subjective history since the HPI describes the abdominal pain as generalized. Gastroenteritis is supported by the subjective history of diarrhea and abdominal pain as well as objective findings of hyperactive bowel sounds.
Diagnostic Tests
Appropriate diagnostic tests for this patient include Ultrasonography of the abdomen, stool microscopy, stool culture, and leukocyte count. Ultrasonography is appropriate to determine the presence of organ enlargement or inflammation, which could be the cause of abdominal pain (Gans et al., 2015). Stool microscopy will be used to examine for ova and parasites to determine if the diarrhea is caused by protozoa (Nemeth & Pfleghaar, 2020). Stool culture will be important to determine the cause of diarrhea such as Salmonella, Shigella, C.difficile, E.coli, Vibrio, or Y.enterocolitica (Nemeth & Pfleghaar, 2020). Leukocyte/ WBC count will determine if the patient has inflammation or infection, causing abdominal pain (Gans et al., 2015). It will also determine the causative pathogen for diarrhea if it is viral or bacterial.
Differential Diagnoses
I would reject the diagnosis of LLQ pain since pain is not considered a diagnosis but a clinical symptom that guides the diagnosis. I would accept Gastroenteritis as a diagnosis since the subjective and objective findings support the diagnosis, including diarrhea, abdominal pain, nausea, and hyperactive bowel sounds. Differential diagnoses for this case can include:
Viral Gastroenteritis
Gastroenteritis refers to an infectious disease of the GI tract. It is caused by one or more bacterial, viral, or protozoa pathogens causing structural or functional damage of variable degree and severity to the mucosa (Desselberger, 2017). Viruses are the causative pathogens in viral Gastroenteritis. The viruses include Rotavirus, Adenovirus, and Astrovirus. Viral Gastroenteritis results in a self-limited watery diarrheal illness that lasts less than one week. Its most common symptoms are acute vomiting and diarrhea.
Associated symptoms include nausea, anorexia, malaise, and fever (Desselberger, 2017). Physical exam findings include slightly elevated temperature, weight loss, dry mucous membrane, hyperactive bowel sounds, and mild abdominal tenderness (Desselberger, 2017). Viral Gastroenteritis is a differential diagnosis based on pertinent positive findings of abdominal pain, diarrhea, nausea, low-grade fever of 99.8F, hyperactive bowel sounds, and abdominal tenderness on palpation.
Acute Diarrhea
Acute diarrhea is characterized by an abrupt onset of three or more loose stools per day and lasts no longer than 14 days. Signs and symptoms of diarrhea include abdominal pain or cramping, perianal erythema, vomiting, abdominal bloating, flatulence, fever, and bloody or mucoid stools (Drancourt, 2017). Patients present with Borborygmi or increased peristaltic activity and signs of dehydration, such as dry mucous membranes, sunken eyes, poor skin turgor, and delayed capillary refill (Drancourt, 2017). Acute diarrhea is a differential diagnosis based on pertinent positive findings of passing frequent loose stools, abdominal pain, and hyperactive bowel sounds.
Acute Diverticulitis
Clinical features of Acute diverticulitis include fever, left lower quadrant pain, and change in bowel habits, either diarrhea or constipation. Left lower abdominal pain is the most common symptom in 70% of patients (Rezapour, Ali & Stollman, 2018). The abdominal pain is mostly described as crampy and is associated with a change in bowel habits. Other symptoms include nausea, vomiting, flatulence, constipation, and bloating (Rezapour et al., 2018). Acute diverticulitis may be due to complications, such as intestinal perforation, colonic abscess, or fistula formation (Rezapour et al., 2018). Acute diverticulitis is a differential diagnosis based on pertinent positive findings of left lower quadrant pain, diarrhea, nausea, and elevated body temperature.
Conclusion
The subjective portion should include additional information that describes the duration, characteristics, aggravating, and alleviating factors of abdominal pain and diarrhea. It should also include the immunization status, frequency of current medications, surgical history, and detailed social history. The SOAP note’s objective portion should have additional information on the general exam findings and detailed abdominal exam findings. Appropriate diagnostic tests for this patient include Ultrasonography of the abdomen, stool microscopy, stool culture, and leukocyte count. The differential diagnoses based on the patient’s subjective history and objective findings include viral Gastroenteritis, Acute Diarrhea, and Acute Diverticulitis.
A woman went to the emergency room for severe abdominal cramping. She was diagnosed with diverticulitis; however, as a precaution, the doctor ordered a CAT scan. The CAT scan revealed a growth on the pancreas, which turned out to be pancreatic cancer—the real cause of the cramping.
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 Assessing the Abdomen: NURS 6512 Discussion, you will consider case studies that describe 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 conditions.
Note: By Day 1 of this week, your Instructor will have assigned you to one of the following specific case studies for this Discussion. Also, your Discussion post should be in the SOAP Note format, rather than the traditional narrative style Discussion posting format. Refer to Chapter 2 of the Sullivan text and the Comprehensive SOAP Template in the Week 4 Learning Resources for guidance. Remember that not all comprehensive SOAP data are included in every patient case.
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Assessing the Abdomen: NURS 6512 Case 1: Abdominal Pain
A 12-year-old female complains of malaise with abdominal pain pointing to the right lower quadrant. The patient has been vomiting
and feeling nauseated for several days. The abdominal pain has been insidious and now is more pronounced. Both parents are with the child and are concerned because she has not been eating and has had a fever for the past 3 evenings.
Assessing the Abdomen: NURS 6512 Case 2: Gastrointestinal Pain
A 50-year-old male complains of burning pain starting at the abdomen and rising to the middle of his chest. He describes the pain as a gnawing feeling that begins after meals, especially when lying down.
Assessing the Abdomen: NURS 6512 Case 3: Nausea and Vomiting
A 20-year-old female complains of nausea and has vomited three times over the past 48 hours. The patient also experienced a low-grade fever this morning. She states that she recently ate shellfish at a new restaurant with two friends who are suffering from similar symptoms.
SOAP Note
Abdominal Assessment
SUBJECTIVE:
• CC: “My stomach hurts, I have diarrhea and nothing seems to help.”
• HPI: JR, 47 yo WM, complains of having generalized abdominal pain that started 3 days ago. He has not taken any medications because he did not know what to take. He states the pain is a 5/10 today but has been as much as 9/10 when it first started. He has been able to eat, with some nausea afterwards.
• PMH: HTN, Diabetes, hx of GI bleed 4 years ago
• Medications: Lisinopril 10mg, Amlodipine 5 mg, Metformin 1000mg, Lantus 10 units qhs
• Allergies: NKDA
• FH: No hx of colon cancer, Father hx DMT2, HTN, Mother hx HTN, Hyperlipidemia, GERD
• Social: Denies tobacco use; occasional etoh, married, 3 children (1 girl, 2 boys)
OBJECTIVE:
• VS: Temp 99.8; BP 160/86; RR 16; P 92; HT 5’10”; WT 248lbs
• Heart: RRR, no murmurs
• Lungs: CTA, chest wall symmetrical
• Skin: Intact without lesions, no urticaria
• Abd: soft, hyperctive bowel sounds, pos pain in the LLQ
• Diagnostics: None
ASSESSMENT:
• Left lower quadrant pain
• Gastroenteritis
• PLAN: This section is not required for the assignments in this course (NURS 6512) but will be required for future
To prepare:
With regard to the case study you were assigned:
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 you were assigned.
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.
Note: Before you submit your initial post, replace the subject line (“Week 7 Discussion”) with “Review of Case Study ___.” Fill in the blank with the number of the case study you were assigned.
By Day 3
Post a description of the health history you would need to collect from the patient in the case study to which you were assigned. Explain which physical exams and diagnostic tests would be appropriate and how the results would be used to make a diagnosis. List five different possible conditions for the patient’s differential diagnosis, and justify why you selected each.
Read a selection of your colleagues’ responses.
By Day 6
Respond to at least two of your colleagues on two different days who were assigned different case studies than you. Analyze the possible conditions from your colleagues’ differential diagnoses. Determine which of the conditions you would reject, and why. Identify the most likely condition, and justify your reasoning.
Note: Before you submit your initial post, replace the subject line (“Week 7 Discussion”) with “Review of Case Study ___.” Fill in the blank with the number of the case study you were assigned.
Post A 1 page paper APA format
1. a description of the health history you would need to collect from the patient in the case study to which you were assigned. (case 2)
2. Explain which physical exams and diagnostic tests would be appropriate and how the results would be used to make a diagnosis.
3. List five different possible conditions for the patient’s differential diagnosis, and justify why you selected each.
Important note (Remember to focus on the appropriate body systems for the clinical scenarios instead of focusing on the whole body system- Usually a complete physical exam is done during an annual wellness visit. This is not a wellness exam .
2. Your diagnosis for the clinical scenario must have a rationale and reasoning as to why
Remember to link the diagnosis to patients symptoms and clinical exam findings along with the rationale)
Assessing the Abdomen: NURS 6512 Course Readings
· Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015). Seidel’s guide to physical examination (8th ed.). St. Louis, MO: Elsevier Mosby.
o Chapter 4, “Vital Signs and Pain Assessment” (pp. 50-63)
This chapter describes the experience of pain and its causes. The authors also describe the process of pain assessment.
o Chapter 17, “Abdomen” (pp. 370-415)
In this chapter, the authors summarize the anatomy and physiology of the abdomen. The authors also explain how to conduct an assessment on the abdomen.
· Dains, J. E., Baumann, L. C., & Scheibel, P. (2016). Advanced health assessment and clinical diagnosis in primary care (5th ed.). St. Louis, MO: Elsevier Mosby.
o Chapter 3, “Abdominal Pain” (pp. 11-32)
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.
o Chapter 10, “Constipation” (pp. 110-117)
The focus of this chapter is on identifying the causes of constipation through taking a focused history, conducting physical examinations, and performing laboratory tests.
o Chapter 12, “Diarrhea” (pp. 133-147)
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.
o Chapter 29, “Rectal Pain, Itching, and Bleeding” (pp. 344-356)
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.
· Sullivan, D. D. (2012). Guide to clinical documentation (2nd ed.). Philadelphia, PA: F. A. Davis.
o Chapter 7, “Admitting a Patient to the Hospital” (pp. 143–188)
Note: Download this Adult Examination Checklist and Abdomen Physical Exam Summary to use during your practice abdominal examination.
· Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2011). Adult examination checklist: Guide for abdominal assessment. In Mosby’s guide to physical examination(7th ed.). St. Louis, MO: Elsevier Mosby.
This Adult Examination Checklist: Guide for Abdominal Assessment was published as a companion to Seidel’s guide to physical examination (8th ed.), by Ball, J. W., Dains, J. E., & Flynn, J. A. Copyright Elsevier (2015). From https://evolve.elsevier.com/
· Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2011). Physical exam summary: Abdomen. In Mosby’s guide to physical examination (7th ed.). St. Louis, MO: Elsevier Mosby.
This Abdomen Physical Exam Summary was published as a companion to Seidel’s guide to physical examination (8th ed.), by Ball, J. W., Dains, J. E., & Flynn, J. A. Copyright Elsevier (2015). From https://evolve.elsevier.com/
· Craig, M., & Infante, S. (2011). Abdominal mysteries: Pain, peritonitis, pancreatitis. Nephrology Nursing Journal, 38(2), 173–186.
Retrieved from the Walden Library databases.
This article explains various types of abdominal pain. The authors detail the etiologies, symptoms, and treatment for the abdominal pain described.
· Mills, A. M., & Chen, E. H. (2011). Abdominal pain in special populations. Emergency Medicine Reports, 32(7), 81–91.
Retrieved from the Walden Library databases.
The authors of this article explore the characteristics and diagnoses associated with abdominal pain in patients with special conditions. The article also provides recommendations for emergency department staff when encountering abdominal pain.
· University of Virginia. (n.d.). Introduction to radiology: An online interactive tutorial. Retrieved fromhttp://www.med-ed.virginia.edu/courses/rad/index.html
This website provides an introduction to radiology and imaging. For this week, focus on gastrointestinal radiology.
NURS 6512 Week 7 Quiz
Question 1 A patient suspected of having a peptic ulcer would receive further routine evaluation with all of the following except:
Question 2 Pulsus paradoxus greater than 20 mm Hg, tachycardia greater than 130 beats per minute, and increasing dyspnea are signs of:
Question 3 A 23-year-old man comes to the urgent care clinic with intense left flank and lower left quadrant pain. One patient response to history of present illness questions that further supports a tentative diagnosis of renal calculi is:
Question 4 Auscultation of borborygmi is associated with:
Question 5 When examining a patient with tense abdominal musculature, a helpful technique is to have the patient:
Question 6 Mrs. G. is 7 months pregnant and states that she has developed a problem with constipation. She eats a well-balanced diet and is usually regular. You should explain that constipation is common during pregnancy due to changes in the colorectal areas, such as:
Question 7 An umbilical assessment in the newborn that is of concern is:
Question 8 In order to assess for liver enlargement in the obese person, you should:
Question 9 A patient presents to the emergency department after a motor vehicle accident. The patient sustained blunt trauma to the abdomen and complains of pain in the upper left quadrant th
