Abdominal Assessment Paper

Abdominal Assessment Paper Abdominal Assessment Paper 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. NURS 6512 Middle Tennessee State University Wk6 Abdominal Assessment 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). Abdominal Assessment Paper 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 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. Abdominal Assessment Paper 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. NURS 6512 Middle Tennessee State University Wk6 Abdominal Assessment 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: 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. THE ASSIGNMENT Analyze the subjective portion of the note. List additional information that should be included in the documentation. Analyze the objective portion of the note. List additional information that should be included in the documentation. Abdominal Assessment Paper Is the assessment supported by the subjective and objective information? Why or why not? What diagnostic tests would be appropriate for this case, and how would the results be used to make a diagnosis? 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. ORDER NOW FOR CUSTOMIZED AND ORIGINAL ESSAY PAPERS rubric_detail_____abdominal_assessment.pdf Unformatted Attachment Preview Abdominal Assessment Paper. Rubric Detail Select Grid View or List View to change the rubric’s layout. Name: NURS_6512_Week_6_Assignment_1_Rubric Grid View EXIT List View Excellent Good Fair Poor 10 (10%) – 12 (12%) 7 (7%) – 9 (9%) 4 (4%) – 6 (6%) 0 (0%) – 3 (3%) 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. The response accurately analyzes the subjective portion of the SOAP note and lists additional information to be included in the documentation. 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. 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. 10 (10%) – 12 (12%) 7 (7%) – 9 (9%) 4 (4%) – 6 (6%) 0 (0%) – 3 (3%) 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. The response accurately analyzes the objective portion of the SOAP note and lists additional information to be included in the documentation. 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. 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? 14 (14%) – 16 (16%) 11 (11%) – 13 (13%) 8 (8%) – 10 (10%) 0 (0%) – 7 (7%) The response clearly and accurately identi!es whether or not the assessment is supported by the subjective and/or objective information, with a thorough and detailed explanation. The response accurately identi!es whether or not the assessment is supported by the subjective and/or objective information, with an explanation. The response vaguely and/or inaccurately identi!es whether or not the assessment is supported by the subjective and/or objective information, with a vague explanation. The response inaccurately identi!es 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? 18 (18%) – 20 (20%) 15 (15%) – 17 (17%) 12 (12%) – 14 (14%) 0 (0%) – 11 (11%) 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. 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. 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. NURS 6512 Middle Tennessee State University Wk6 Abdominal Assessment Abdominal Assessment Paper. 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 di!erenial diagnosis for this patient. Explain your reasoning using at least three di!erent references from current evidence-based literature. 23 (23%) – 25 (25%) 20 (20%) – 22 (22%) 17 (17%) – 19 (19%) 0 (0%) – 16 (16%) 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 identi!es three conditions as a di”erential diagnosis, with reasoning that is explained clearly, accurately, and thoroughly using at least three di”erent references from current evidence-based literature. The response states whether to accept or reject the current diagnosis, with an accurate explanation of sound reasoning. The response accurately identi!es three conditions as a di”erential diagnosis, with reasoning that is explained accurately using three di”erent references from current evidence-based literature. The response states whether to accept or reject the current diagnosis, with a vague explanation of the reasoning. The response identi!es two or three conditions as a di”erential diagnosis, with reasoning that is explained vaguely and/or inaccurately using three references from current evidencebased literature. 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 identi!es two or fewer conditions as a di”erential 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, “ow 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 (5%) – 5 (5%) 4 (4%) – 4 (4%) 3 (3%) – 3 (3%) 0 (0%) – 2 (2%) Paragraphs and sentences follow writing standards for #ow, continuity, and clarity. A clear and comprehensive purpose statement, introduction, and conclusion are provided that delineate all required criteria. Paragraphs and sentences follow writing standards for #ow, continuity, and clarity 80% of the time. Purpose, introduction, and conclusion of the assignment are stated, yet are brief and not descriptive. Paragraphs and sentences follow writing standards for #ow, continuity, and clarity 60%–79% of the time. Purpose, introduction, and conclusion of the assignment are vague or o” topic. Paragraphs and sentences follow writing standards for #ow, continuity, and clarity < 60% of the time. NURS 6512 Middle Tennessee State University Wk6 Abdominal Assessment No purpose statement, introduction, or conclusion were provided. Written Expression and Formatting English writing standards: Correct grammar, mechanics, and proper punctuation 5 (5%) – 5 (5%) 4 (4%) – 4 (4%) 3 (3%) – 3 (3%) 0 (0%) – 2 (2%) Uses correct grammar, spelling, and punctuation with no errors. Contains a few (1 or 2) grammar, spelling, and punctuation errors. Contains several (3 or 4) grammar, spelling, and punctuation errors. 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. 5 (5%) – 5 (5%) 4 (4%) – 4 (4%) 3 (3%) – 3 (3%) 0 (0%) – 2 (2%) Uses correct APA format with no errors. Contains a few (1 or 2) APA format errors. Contains several (3 or 4) APA format errors. Contains many (? 5) APA format errors. With 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. Total Points: 100 Name: NURS_6512_Week_6_Assignment_1_Rubric EXIT … Purchase answer to see full attachment Student has agreed that all tutoring, explanations, and answers provided by the tutor will be used to help in the learning process and in accordance with Studypool’s honor code & terms of service . Get a 10 % discount on an order above $ 100 Use the following coupon code : NURSING10