Week 6: Assessment of the Abdomen and Gastrointestinal System

On your way home from dinner, you start experiencing sharp pains in your abdomen. You ate seafood—could you have food poisoning? What else might be causing your pain? Appendicitis? Should you head to the emergency room, or should you wait and see how you feel in the morning?

Numerous ailments can affect the GI system and the abdomen. Because the organs are so close, it can be difficult to conduct an accurate assessment. Also, pain in another area of the body can affect the GI system. For example, patients with chronic migraines often report nausea.

This week, you will explore how to assess the abdomen and gastrointestinal system.

Learning Objectives

Students will:

  •  
  • Evaluate abnormal abdomen and gastrointestinal findings
  • Apply concepts, theories, and principles relating to health assessment techniques and diagnoses for the abdomen and gastrointestinal system
  • Identify  concepts, theories, and principles related to advanced health assessment

Learning Resources

 

Required Readings (click to expand/reduce)

 

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.

 

·         Chapter 6, “Vital Signs and Pain Assessment” This chapter describes the experience of pain and its causes. The authors also describe the process of pain assessment.

 

·         Chapter 18, “Abdomen” In this chapter, the authors summarize the anatomy and physiology of the abdomen. The authors also explain how to conduct an assessment of the abdomen.

Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Advanced health assessment and clinical diagnosis in primary care (6th ed.). St. Louis, MO: Elsevier Mosby.

Credit Line: Advanced Health Assessment and Clinical Diagnosis in Primary Care, 6th Edition by Dains, J.E., Baumann, L. C., & Scheibel, P. Copyright 2019 by Mosby. Reprinted by permission of Mosby via the Copyright Clearance Center.

 

Chapter 3, “Abdominal Pain” 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.

 

Chapter 10, “Constipation” The focus of this chapter is on identifying the causes of constipation through taking a focused history, conducting physical examinations, and performing laboratory tests.

 

Chapter 12, “Diarrhea” 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.

 

Chapter 29, “Rectal Pain, Itching, and Bleeding” 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.

 

Colyar, M. R. (2015). Advanced practice nursing procedures. Philadelphia, PA: F. A. Davis.

Credit Line: Advanced practice nursing procedures, 1st Edition by Colyar, M. R. Copyright 2015 by F. A. Davis Company. Reprinted by permission of F. A. Davis Company via the Copyright Clearance Center.

 

These sections below explain the procedural knowledge needed to perform gastrointestinal procedures.

 

Chapter 107, “X-Ray Interpretation: Chest (pp. 480–487)

 

Chapter 115, “X-Ray Interpretation of Abdomen” (pp. 514–520)

 

 

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Abdomen: Key points. In Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.

Credit Line: Seidel’s Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the Copyright Clearance Center.

 

 

Optional Resource

LeBlond, R. F., Brown, D. D., & DeGowin, R. L. (2014). DeGowin’s diagnostic examination (10th ed.). New York, NY: McGraw Hill Medical.

 

·         Chapter 9, “The Abdomen, Perineum, Anus, and Rectosigmoid” (pp. 445–527) This chapter explores the health assessment processes for the abdomen, perineum, anus, and rectosigmoid. This chapter also examines the symptoms of many conditions in these areas. 

·         Chapter 10, “The Urinary System” (pp. 528–540) In this chapter, the authors provide an overview of the physiology of the urinary system. The chapter also lists symptoms and conditions of the urinary system.

 

Assignment 1: Lab Assignment: Assessing the Abdomen

 

Photo Credit: Getty Images/Hero Images

A woman went to the emergency room for severe abdominal cramping. She was diagnosed with diverticulitis; however, as a precaution, the doctor ordered a CT scan. The CT 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 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 conditions.

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:

The Assignment

  1. Analyze the subjective portion of the note. List additional information that should be included in the documentation.
  2. Analyze the objective portion of the note. List additional information that should be included in the documentation.
  3. Is the assessment supported by the 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.

Rubric Detail

A rubric lists grading criteria that instructors use to evaluate student work. Your instructor linked a rubric to this item and made it available to you. Select Grid View or List View to change the rubric’s layout.

Content

Name: NURS_6512_Week_6_Assignment_1_Rubric

 

 

ExcellentGoodFairPoorWith 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.

Points Range:10 (10.00%) – 12 (12.00%)

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.

Points Range:7 (7.00%) – 9 (9.00%)

The response accurately analyzes the subjective portion of the SOAP note and lists additional information to be included in the documentation.

Points Range:4 (4.00%) – 6 (6.00%)

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.

Points Range:0 (0.00%) – 3 (3.00%)

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.

Analyze the objective portion of the note. List additional information that should be included in the documentation.

Points Range:10 (10.00%) – 12 (12.00%)

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.

Points Range:7 (7.00%) – 9 (9.00%)

The response accurately analyzes the objective portion of the SOAP note and lists additional information to be included in the documentation.

Points Range:4 (4.00%) – 6 (6.00%)

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.

Points Range:0 (0.00%) – 3 (3.00%)

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.

Is the assessment supported by the subjective and objective information? Why or why not?

Points Range:14 (14.00%) – 16 (16.00%)

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.

Points Range:11 (11.00%) – 13 (13.00%)

The response accurately identifies whether or not the assessment is supported by the subjective and/or objective information, with an explanation.

Points Range:8 (8.00%) – 10 (10.00%)

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.

Points Range:0 (0.00%) – 7 (7.00%)

The response inaccurately identifies whether or not the assessment is supported by the subjective and/or objective information, with an inaccurate or missing explanation.

What diagnostic tests would be appropriate for this case, and how would the results be used to make a diagnosis?

Points Range:18 (18.00%) – 20 (20.00%)

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.

Points Range:15 (15.00%) – 17 (17.00%)

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.

Points Range:12 (12.00%) – 14 (14.00%)

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.

Points Range:0 (0.00%) – 11 (11.00%)

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.

·   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.

Points Range:23 (23.00%) – 25 (25.00%)

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.

Points Range:20 (20.00%) – 22 (22.00%)

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.

Points Range:17 (17.00%) – 19 (19.00%)

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.

Points Range:0 (0.00%) – 16 (16.00%)

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.

Written 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.

Points Range:5 (5.00%) – 5 (5.00%)

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.

Points Range:4 (4.00%) – 4 (4.00%)

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.

Points Range:3 (3.00%) – 3 (3.00%)

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.

Points Range:0 (0.00%) – 2 (2.00%)

Paragraphs and sentences follow writing standards for flow, continuity, and clarity < 60% of the time. No purpose statement, introduction, or conclusion were provided.

Written Expression and Formatting – English writing standards:Correct grammar, mechanics, and proper punctuation

Points Range:5 (5.00%) – 5 (5.00%)

Uses correct grammar, spelling, and punctuation with no errors.

Points Range:4 (4.00%) – 4 (4.00%)

Contains a few (1 or 2) grammar, spelling, and punctuation errors.

Points Range:3 (3.00%) – 3 (3.00%)

Contains several (3 or 4) grammar, spelling, and punctuation errors.

Points Range:0 (0.00%) – 2 (2.00%)

Contains many (≥ 5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding.

Written 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.

Points Range:5 (5.00%) – 5 (5.00%)

Uses correct APA format with no errors.

Points Range:4 (4.00%) – 4 (4.00%)

Contains a few (1 or 2) APA format errors.

Points Range:3 (3.00%) – 3 (3.00%)

Contains several (3 or 4) APA format errors.

Points Range:0 (0.00%) – 2 (2.00%)

Contains many (≥ 5) APA format errors.

Name:NURS_6512_Week_6_Assignment_1_Rubric

 

 

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The Assignment

  1. Analyze the subjective portion of the note. List additional information that should be included in the documentation.
  2. Analyze the objective portion of the note. List additional information that should be included in the documentation.
  3. Is the assessment supported by the 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 five 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.

In this Assessment 1 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 conditions.

Review the following Episodic note case study for this Assignment: See Below

Assessment of the Abdomen and

Gastrointestinal System

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, hyperactive bowel sounds, pos pain in the LLQ

• Diagnostics: None

Assessment:

• Left lower quadrant pain

• Gastroenteritis

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