NURS 6512 Assignment 1: Lab Assignment: Assessing the Abdomen

NURS 6512 Assignment 1: Lab Assignment: Assessing the Abdomen

NURS 6512 Assignment 1: Lab Assignment: Assessing the Abdomen

Subjective Portion Analysis

Appropriate clinical diagnosis and the development of personalized treatment plans for specific patients need a rigorous healthcare assessment. As such, more information on the nature of patient LZ’s pain is needed.  What are the characteristics and severity of the client’s pain? What triggered the onset of the pain? Was it a progressive pain, or did he suddenly feel the effects of the pain? This necessitates a thorough examination of the patient’s symptoms to determine what kind of pain he is experiencing (Ball et al., 2017). It is important for the practitioner to get further information about the conditions that have caused the pain to increase or intensify. Other questions that a clinician should ask include: How would you rate your current level of pain? What is the highest number on a scale of one to ten? Is there any medicine you’ve taken in the last week? Have you had any surgical procedures performed on you? Do you experience greater pain when you are lying down than when you are sitting upright?

Objective Portion Analysis

There are critical things missing from the soap note when it comes to the objective information. The overall appearance of the client must be described in the objective component of the note.  It is also necessary to record the patient’s level of consciousness. The findings of any laboratory tests performed, such as abdominal ultrasound and CT scan should be documented. Apart from the vital signs, heart, lungs, skin, and abdomen evaluation, the practitioner should additionally incorporate the client’s facial expression while assessing his painful area, the color of his skin, abdominal bloating, and whether or not he has excessive sweating.

Is the assessment supported by subjective and objective information?

The assessment is supported by the subjective and objective data. The patient has a history of abdominal pain that has become more severe over time, and he has also vomited. Furthermore, he reports pain in the epigastric region and guarding, which is in line with abdominal pain. Diagnostic tests such as the ultrasound and CT scan might provide additional findings to validate the assessment.

 Appropriate Diagnostic Tests

In order to determine the presence of infection and bleeding, a complete blood count will be required. Amylase and

lipase tests are also required since a high lipase level in the presence of a normal amylase level indicates that pancreatitis is unlikely to be the cause. Abdominal ultrasonography is the most often used diagnostic to identify abdominal aortic aneurysms, perforated ulcers, and other abdominal abnormalities. It will also be essential to perform an abdominal CT scan, which is a non-invasive examination that employs X-rays to make cross-sectional pictures of the components within the abdominal region. An endoscopy will be performed to evaluate the upper digestive tract, and a abdominal/chest X-ray will be taken since air beneath the diaphragm may indicate a perforated ulcer.

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 Reject/Accept the Current Diagnosis

I accept the diagnosis of acute pancreatitis; however I disagree with the diagnoses of abdominal aortic aneurysm and perforated ulcer. The symptoms of abdominal aortic aneurysm include abdominal pain, leg pain, and a pulsating belly. However, these indications are not apparent in this case, and as a result, I reject. I also reject the diagnosis of perforated ulcer since the pain linked with this condition does not spread to the back.

Three Possible Conditions

• Acute Pancreatitis:Acute pancreatitis is defined as pancreatic inflammation that occurs suddenly (Mederos et al., 2021). The most common symptom is abdominal pain. It normally subsides after a few days, although it may often become serious and life-threatening. Gallstones and excessive alcohol use are the two most prevalent causes of acute pancreatitis.
• Cholecystitis:Cholecystitis is a condition in which the gallbladder becomes inflamed. It is often caused by gallstones obstructing the tube coming from the gallbladder. This leads in an accumulation of bile, which might result in inflammation. Some of the other possible causes of cholecystitis include abnormalities with the bile ducts or tumors, as well as acute disease and some infections (Balmadrid, 2018). Right upper abdominal pain, soreness in the right shoulder, vomiting, nausea, and, on rare occasions, fever are all symptoms of this condition. Prescription painkillers (PPIs) do not alleviate the pain.

Gastritis: Gastritis is a term that refers to a range of illnesses that are characterized by inflammation of the stomach’s lining. Gastritis is most commonly caused by infection with the same bacteria that cause most gastrointestinal ulcers, or by the persistent use of certain pain medications such as aspirin. Upper stomach pain, vomiting, and nausea are some of the symptoms. Symptoms may not appear at all in other cases.

References

Azer, S. A., & Akhondi, H. (2019). Gastritis. https://europepmc.org/article/nbk/nbk544250

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2017). Seidel’s Guide to

Balmadrid, B. (2018). Recent advances in management of acalculous cholecystitis. F1000Research, 7, 1660. https://doi.org/10.12688/f1000research.14886.1

Mederos, M. A., Reber, H. A., & Girgis, M. D. (2021). Acute pancreatitis. JAMA, 325(4), 382. https://doi.org/10.1001/jama.2020.20317

CC: “My stomach hurts, I have diarrhea, and nothing seems to help.”

History of Present Illness (HPI): JR is a 47-year-old Caucasian male who came to the hospital complaining of generalized abdominal pain which began three days before the present visit. He denies having taken any drug claiming that she had no idea of what to take. He claims that the severity of the pain currently is 5/10 but was worse of up to 9/10 for the past two days. She has been able to eat properly with the pain but complains of being nauseated afterward.

Medications: Lisinopril 10mg. Amlodipine 5 mg. Metformin 1g. Linctus 10 units qhs

Allergies: No known drug allergies

PMHx: HTN. Diabetes. She has a history of gastrointestinal bleeding which occurred four years ago

PSHx: No past surgical history

Sexual/Reproductive History: He is heterosexual and has three children, two boys, and one girl

Soc Hx: He is married and has three children, two boys, and one girl. Denies ever using tobacco. Confirms alcohol use occasionally.

Significant Fam Hx: He has three children, two boys, and one girl. No family history of colon cancer. The father had a history of type 2 diabetes mellitus and HTN. The mother has a history of HTN, GERD, and hyperlipidemia

Review of Systems:

General: He has been eating properly without any difficulties, despite nausea that comes afterward. He has no fever or loss of appetite.

HEENT: Denies itchy nose, palate, eyes, or ears. No problems with nose bleeding, hearing, ringing sound on the ears.

Skin: Intact skin with no lesions, itchiness, urticarial, Acne, Blistering, Dry skin, hives, Eczema, Moles, Nodules, skin oozing or skin cancer.

Respiratory: No coughing, shortness of breath or hemoptysis. CTA, the walls of her chest are well symmetrical. No history of asthma.

Cardiovascular/Peripheral Vascular: no heart murmurs, chest pain, accumulation of fluid or edema of the legs. Denies pain on palpitation or irregular heartbeats.

Gastrointestinal: Complains of severe generalized abdominal pain which has lasted for three days. Denies decreased in appetite. Confirms nausea after eating. Has a history of blood in stool, four years ago. Denies constipation, heartburn, hematemesis, or rectal bleeding.

Musculoskeletal:  No unsteady gait or deformities. Confirms having a full range of motion and an excellent bilateral strength in all extremities. Denies pain in the joints or fatigue.

Psychiatric: No anxiety, delusion, auditory/visual hallucinations, depressed mood, homicidal disorder, eating disorder, mental or physical abuse, suicidal thoughts or substance abuse.

Neurological: No difficulties in balance, fainting, coordination, or abnormality in gait. Denies loss of strength, or Tingling/Numbness symptoms.

OBJECTIVE DATA:  

P/E:

Vital signs: Temp 99.8; RR 16; BP 160/86; P 92; WT 248lbs; HT 5’10”; BMI 35

Pain: reports abdominal pain severity of 5/10 currently but 9/10 in the last two days. General: The patient is alert and well oriented. The patient can communicate clearly with no difficulties in answering all the questions asked. He maintains good hygiene and seems not to be anxious.

HEENT: pupils are equally dilated, round, bilaterally reactive to light with perfect accommodation. The extraocular movement is intact (EOMI). Clear auditory canal with an intact tympanic membrane. The light reflex presents bilaterally — no signs of enlarged tonsils or mouth wounds.

Skin: The skin is clean and moist, with no signs of scaling, itchiness or moles.

Chest: The thorax is perfectly symmetrical; there are no signs of gross rib deformity. The chest shape and expansion are normal.

Lungs: No diminishing breathing sounds noted, no rales or expiratory wheezes, no rhonchi, wet, and productive cough noted.

Heart:  The heart sounds are normal. No murmurs. Regular heart rate and rhythm. The heart rate is regular with the presence of S1, S2, and absence of S3 or S4.

Peripheral Vascular: No signs of edema, ulcers, varicose veins or deformities. No signs of pedal edema. 2+ dorsalis pedis pulses bilaterally confirmed.

Abdomen: generalized tenderness, hyperactive bowel sounds in all the four quadrants, severe pain on the LLQ. No signs of distention or hernia.

Musculoskeletal: Very steady gait with no deformities. Exhibits full range of motion in all extremities — no pain on movement of joints.

Neurological: Very alert and oriented in a good position. Tolerates appropriately to the tests performed — perfect tone with no history of neurological disorders.

Diagnostics: None

ASSESSMENT:

Pain in the Left lower quadrant of the abdomen.

Gastroenteritis– a viral or bacterial infection of the stomach and intestines causing irritations and inflammation of GI lining. Presents with symptoms such as watery diarrhea, nausea and vomiting, abdominal cramping and pain, fever, and a headache (Mayumi et al., 2016).

Current Diagnosis

The current diagnosis of gastroenteritis is inappropriate due to lack of enough information based on the provided data. It has been supported by limited objective and subjective data, which makes it unacceptable. The advanced practice nurse needs additional subjective and objective data in addition to proper diagnostic lab test result to make a firm diagnosis to avoid the high chances of misdiagnosis (Jamal et al., 2017). These lab tests will also make it possible to differentiate and rule out the following differential diagnosis:

1. Diverticulitis
2. Chron’s
3. Ulcerative colitis
4. Colon cancer
5. Gastroenteritis
6. Food poisoning

Diagnostic Tests Required

For proper diagnosis, the nurse in charge needs to order tests such as colonoscopy, stool occult test, liver function tests, biopsy, and CT scan when necessary. The stool occult tests will provide information confirming the cause of the GI bleeding. The liver function test, on the other hand, will measure the patient’s levels of alanine transferase, albumin, alkaline phosphate, aspartate aminotransferase, and bilirubin to rule out any injuries or liver infections (Othman et al., 2017). The CT scan will provide a proper visual of the abdomen to determine any injuries to any organ, or abnormal growth or any mass blockage within the abdomen. Lastly, the biopsy will determine the actual disease affecting a particular body tissue.

Differential Diagnosis

1. Diverticulitis: this is a chronic inflammatory condition or infection of small pouches known as diverticular which develop along the intestinal walls. This infection results in small abscess along the intestinal lining together with massive perforations of the bowel (Chuong et al., 2016). It results in cramping of the left side of the abdomen and diarrhea in addition to the presence of bright red blood in the patient’s stool, which is positive in the provided case. Other symptoms include fever, nausea, and
2. Chron’s: it is a type of inflammatory bowel disease caused by inflammation of the GI tract. It presents mostly with abdominal pain, severe diarrhea and bloody stool of which the patient is positive for (Zafar et al., 2015). Other sign and symptoms include fever, fatigue, mouth sores, anorexia, weight loss and fistula around the anal region.
3. Ulcerative colitis: It is an inflammatory condition of the colon, rectum or both areas, with ulceration of the colon lining (Bonovas et al., 2018). Patients with this condition usually complain of symptoms such as abdominal pain, severe diarrhea, and bloody stool just like the patient in the above case study. Other symptoms include rectal pain, the urgency to defecate, weight loss, fever, fatigue, and inability to defecate despite the urgency.

PLAN: N/A

References

Mayumi, T., Yoshida, M., Tazuma, S., Mizooka, M., Furukawa, A., Nishii, O., Shigematsu, K., … Hirata, K. (January 01, 2016). The Practice Guidelines for Primary Care of Acute Abdomen 2015. Japanese Journal of Radiology, 34, 1, 80-115.

Jamal, T. A., Edna, T.-H., Jamal, T. A., Edna, T.-H., Endreseth, B. H., Endreseth, B. H., & Lydersen, S. (January 01, 2017). Clinical diagnostic accuracy of acute colonic diverticulitis in patients admitted with acute abdominal pain, a receiver operating characteristic curve analysis. International Journal of Colorectal Disease, 32, 1, 41-47.

Othman, A. E., Bongers, M. N., Zinsser, D., Schabel, C., Wichmann, J. L., Arshid, R., Notohamiprodjo, M., … Bamberg, F. (April 13, 2017). Evaluation of reduced-dose CT for acute non-traumatic abdominal pain: evaluation of diagnostic accuracy in comparison to standard-dose CT. Acta Radiologica, 59, 1, 4-12.

Zafar, H. M., Chadalavada, S. C., Kahn, C. E., Cook, T. S., Sloan, C. E., Lalevic, D., Schnall, M. D., … Langlotz, C. P. (September 01, 2015). Code abdomen: An assessment coding scheme for abdominal imaging findings possibly representing cancer. Journal of the American College of Radiology, 12, 9, 947-950.

Chuong, A. M., Corno, L., Beaussier, H., Boulay-Coletta, I., Millet, I., Hodel, J., Taourel, P., … Zins, M. (January 01, 2016). Assessment of Bowel Wall Enhancement for the Diagnosis of Intestinal Ischemia in Patients with Small Bowel Obstruction: Value of Adding Unenhanced CT to Contrast-enhanced CT. Radiology, 280, 1, 98-107.

Bonovas, S., Lytras, T., Nikolopoulos, G., Peyrin-Biroulet, L., & Danese, S. (January 01, 2018). Systematic review with network meta-analysis: comparative assessment of tofacitinib and biological therapies for moderate-to-severe ulcerative colitis. Alimentary Pharmacology & Therapeutics, 47, 4, 454-465.