LAB ASSIGNMENT: ASSESSING THE ABDOMEN
Order Instructions
Reminder: All papers submitted include a title page, introduction, summary, and references. The Sample Paper provided All papers submitted must use this formatting.
(Uploaded) Assignment 1-Accessing the Abdomen
A male went to the emergency room for severe midepigastric abdominal pain. He was diagnosed with AAA ; however, as a precaution, the doctor ordered a CTA scan.
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 Lab Assignment, you will analyze an Episodic note case study that describes 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
Be sure to review the Learning Resources (uploaded) before completing this activity. Click the weekly resources link to access the resources.
Review the Episodic note case study provided below. With regard to the Episodic note case study provided: 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. 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.
To Prepare
Review the Episodic note case study provided below for this week’s Assignment.
• With regard to the Episodic note case study provided:
o Review this week’s Learning Resources, and consider the insights they provide about the case study.
o Consider what history would be necessary to collect from the patient in the case study.
o 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?
o Identify at least five possible conditions that may be considered in a differential diagnosis for the patient. This means differential diagnosis related to abdominal pain.
Week 6: Assessment of the Abdomen and Gastrointestinal System (Case Study)
ABDOMINAL ASSESSMENT
CASE STUDY
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 PPI’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
Objective:
• VS: Temp 98.2; BP 91/60; RR 16; P 76; HT 6’10”; 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:
1. Abdominal Aortic Aneurysm (AAA)
2. Perforated Ulcer
3. Pancreatitis
PLAN: This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.
Please review the assignment rubric before submitting your assignment. Don’t assume you know the grading criteria!!! This will help to guide you of what is required in your paper.
LAB ASSIGNMENT: ASSESSING THE ABDOMEN
A male went to the emergency room for severe midepigastric abdominal pain. He was diagnosed with AAA ; however, as a precaution, the doctor ordered a CTA scan.
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 Lab Assignment, you will analyze an Episodic note case study that describes 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
RESOURCES
Be sure to review the Learning Resources (uploaded) before completing this activity.
Click the weekly resources link to access the resources.
TO PREPARE
Review the Episodic note case study your instructor provides you for this week’s Assignment. Please see the “Course Announcements” section of the classroom for your Episodic note case study.
• With regard to the Episodic note case study provided:
o Review this week’s Learning Resources, and consider the insights they provide about the case study.
o Consider what history would be necessary to collect from the patient in the case study.
o 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?
o Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.
THE ASSIGNMENT – Write a narrative essay about the following questions.
1. Analyze the subjective portion of the case study. List additional information that should be included in the documentation.
2. Analyze the objective portion of the case study. List additional information that should be included in the documentation.
3. Is the assessment supported by subjective and objective information? Why or why not?
4. What diagnostic tests would be appropriate for this case, and how would the results be used to make a diagnosis?
5. 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.
WE NEED TO SATISFY WHAT RUBRIC REQUIRES.
Rubric (uploaded)
NURS_6512_Week_6_Assignment_1_Rubric
NURS_6512_Week_6_Assignment_1_Rubric
Criteria Ratings Pts
This criterion is linked to a Learning OutcomeWith regard to the SOAP note case study provided, address the following:Analyze the subjective portion of the note. List additional information that should be included in the documentation. 12 to >9.0 pts
Excellent
The response clearly, accurately, and thoroughly analyzes the subjective portion of the SOAP note and lists detailed additional information to be included in the documentation. 9 to >6.0 pts
Good
The response accurately analyzes the subjective portion of the SOAP note and lists additional information to be included in the documentation. 6 to >3.0 pts
Fair
The response vaguely and/or with some inaccuracy analyzes the subjective portion of the SOAP note and vaguely and/or with some inaccuracy lists additional information to be included in the documentation. 3 to >0 pts
Poor
The response inaccurately analyzes or is missing analysis of the subjective portion of the SOAP note, with inaccurate and/or missing additional information included in the documentation.
12 pts
This criterion is linked to a Learning OutcomeAnalyze the objective portion of the note. List additional information that should be included in the documentation. 12 to >9.0 pts
Excellent
The response clearly, accurately, and thoroughly analyzes the objective portion of the SOAP note and lists detailed additional information to be included in the documentation. 9 to >6.0 pts
Good
The response accurately analyzes the objective portion of the SOAP note and lists additional information to be included in the documentation. 6 to >3.0 pts
Fair
The response vaguely and/or with some inaccuracy analyzes the objective portion of the SOAP note and vaguely and/or inaccurately lists additional information to be included in the documentation. 3 to >0 pts
Poor
The response inaccurately analyzes or is missing analysis of the objective portion of the SOAP note, with inaccurate and/or missing additional information included in the documentation.
12 pts
This criterion is linked to a Learning OutcomeIs the assessment supported by the subjective and objective information? Why or why not? 16 to >13.0 pts
Excellent
The response clearly and accurately identifies whether or not the assessment is supported by the subjective and/or objective information, with a thorough and detailed explanation. 13 to >10.0 pts
Good
The response accurately identifies whether or not the assessment is supported by the subjective and/or objective information, with an explanation. 10 to >7.0 pts
Fair
The response vaguely and/or inaccurately identifies whether or not the assessment is supported by the subjective and/or objective information, with a vague explanation. 7 to >0 pts
Poor
The response inaccurately identifies whether or not the assessment is supported by the subjective and/or objective information, with an inaccurate or missing explanation.
16 pts
This criterion is linked to a Learning OutcomeWhat diagnostic tests would be appropriate for this case, and how would the results be used to make a diagnosis? 20 to >17.0 pts
Excellent
The response thoroughly and accurately describes appropriate diagnostic tests for the case and explains clearly, thoroughly, and accurately how the test results would be used to make a diagnosis. 17 to >14.0 pts
Good
The response accurately describes appropriate diagnostic tests for the case and explains clearly and accurately how the test results would be used to make a diagnosis. 14 to >11.0 pts
Fair
The response vaguely and/or with some inaccuracy describes appropriate diagnostic tests for the case and vaguely and/or with some inaccuracy explains how the test results would be used to make a diagnosis. 11 to >0 pts
Poor
The response inaccurately describes appropriate diagnostic tests for the case, with an inaccurate or missing explanation of how the test results would be used to make a diagnosis.
20 pts
This criterion is linked to a Learning Outcome· Would you reject or accept the current diagnosis? Why or why not?· Identify three possible conditions that may be considered as a differenial diagnosis for this patient. Explain your reasoning using at least three different references from current evidence-based literature. 25 to >22.0 pts
Excellent
The response states clearly whether to accept or reject the current diagnosis, with a thorough, accurate, and detailed explanation of sound reasoning. The response clearly, thoroughly, and accurately identifies three conditions as a differential diagnosis, with reasoning that is explained clearly, accurately, and thoroughly using at least three different references from current evidence-based literature. 22 to >19.0 pts
Good
The response states whether to accept or reject the current diagnosis, with an accurate explanation of sound reasoning. The response accurately identifies three conditions as a differential diagnosis, with reasoning that is explained accurately using three different references from current evidence-based literature. 19 to >16.0 pts
Fair
The response states whether to accept or reject the current diagnosis, with a vague explanation of the reasoning. The response identifies two or three conditions as a differential diagnosis, with reasoning that is explained vaguely and/or inaccurately using three references from current evidence-based literature. 16 to >0 pts
Poor
The response inaccurately or is missing a statement of whether to accept or reject the current diagnosis, with an explanation that is inaccurate and/or missing. The response identifies two or fewer conditions as a differential diagnosis, with reasoning that is missing or explained inaccurately using three or fewer references from current evidence-based literature.
25 pts
This criterion is linked to a Learning OutcomeWritten Expression and Formatting – Paragraph Development and Organization: Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused–neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria. 5 to >4.0 pts
Excellent
Paragraphs and sentences follow writing standards for flow, continuity, and clarity. A clear and comprehensive purpose statement, introduction, and conclusion are provided that delineate all required criteria. 4 to >3.0 pts
Good
Paragraphs and sentences follow writing standards for flow, continuity, and clarity 80% of the time. Purpose, introduction, and conclusion of the assignment are stated, yet are brief and not descriptive. 3 to >2.0 pts
Fair
Paragraphs and sentences follow writing standards for flow, continuity, and clarity 60%–79% of the time. Purpose, introduction, and conclusion of the assignment are vague or off topic. 2 to >0 pts
Poor
Paragraphs and sentences follow writing standards for flow, continuity, and clarity < 60% of the time. No purpose statement, introduction, or conclusion were provided.
5 pts
This criterion is linked to a Learning OutcomeWritten Expression and Formatting – English writing standards: Correct grammar, mechanics, and proper punctuation 5 to >4.0 pts
Excellent
Uses correct grammar, spelling, and punctuation with no errors. 4 to >3.0 pts
Good
Contains a few (1 or 2) grammar, spelling, and punctuation errors. 3 to >2.0 pts
Fair
Contains several (3 or 4) grammar, spelling, and punctuation errors. 2 to >0 pts
Poor
Contains many (≥ 5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding.
5 pts
This criterion is linked to a Learning OutcomeWritten Expression and Formatting – The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, running heads, parenthetical/in-text citations, and reference list. 5 to >4.0 pts
Excellent
Uses correct APA format with no errors. 4 to >3.0 pts
Good
Contains a few (1 or 2) APA format errors. 3 to >2.0 pts
Fair
Contains several (3 or 4) APA format errors. 2 to >0 pts
Poor
Contains many (≥ 5) APA format errors.
5 pts
Total Points: 100
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