Posted: September 16th, 2022

Advanced Health Assessment and Diagnostic Reasoning

Advanced Health Assessment & Diagnostic Reasoning
Week 6 Case Examine

Week 6: Assessment of the Stomach and Gastrointestinal System ABDOMINAL ASSESSMENT Subjective: • CC: “My abdomen hurts, I’ve diarrhea and nothing appears to Help.” • HPI: JR, 47 yo WM, complains of getting generalized belly ache that began three days in the past. He has not taken any drugs as a result of he didn’t know what to take. He states the ache is a 5/10 at the moment however has been as a lot as 9/10 when it first began. He has been in a position to eat, with some nausea afterwards. • PMH: HTN, Diabetes, hx of GI bleed four years in the past • Medicines: Lisinopril 10mg, Amlodipine 5 mg, Metformin 1000mg, Lantus 10 models qhs • Allergy symptoms: NKDA • FH: No hx of colon most cancers, Father hx DMT2, HTN, Mom hx HTN, Hyperlipidemia, GERD • Social: Denies tobacco use; occasional etoh, married, three kids (1 woman, 2 boys) Goal: • VS: Temp 99.eight; BP 160/86; RR 16; P 92; HT 5’10”; WT 248lbs • Coronary heart: RRR, no murmurs • Lungs: CTA, chest wall symmetrical • Pores and skin: Intact with out lesions, no urticaria • Abd: tender, hyperactive bowel sounds, pos ache within the LLQ • Diagnostics: None Assessment: • Left decrease quadrant ache • Gastroenteritis PLAN: This part will not be required for the assignments on this course (NURS 6512) however shall be required for future programs.
Project 1: Lab Project: Assessing the Stomach

Photograph Credit score: Getty Pictures/Hero Pictures

A girl went to the emergency room for extreme belly cramping. She was recognized with diverticulitis; nevertheless, as a precaution, the physician ordered a CT scan. The CT scan revealed a progress on the pancreas, which turned out to be pancreatic most cancers—the actual explanation for the cramping.

Due to a excessive potential for misdiagnosis, figuring out the exact explanation for belly ache might be time consuming and difficult. By analyzing case research of irregular belly findings, nurses can put together themselves to raised diagnose situations within the stomach.

On this Lab Project, you’ll analyze an Episodic word case research that describes irregular findings in sufferers seen in a scientific setting. You’ll think about what historical past needs to be collected from the sufferers in addition to which bodily exams and diagnostic checks needs to be performed. Additionally, you will formulate a differential prognosis with a number of potential situations.
To Put together

Assessment the Episodic word case research your teacher supplies you for this week’s Project. Please see the “Course Bulletins” part of the classroom to your Episodic word case research.

With regard to the Episodic word case research offered:
Assessment this week’s Studying Assets, and think about the insights they supply in regards to the case research.
Contemplate what historical past can be essential to gather from the affected person within the case research.
Contemplate what bodily exams and diagnostic checks can be acceptable to assemble extra details about the affected person’s situation. How would the outcomes be used to make a prognosis?
Determine not less than 5 potential situations that could be thought-about in a differential prognosis for the affected person.

The Project

Analyze the subjective portion of the word. Record extra data that needs to be included within the documentation.
Analyze the target portion of the word. Record extra data that needs to be included within the documentation.
Is the Assessment supported by the subjective and goal data? Why or why not?
What diagnostic checks can be acceptable for this case, and how would the outcomes be used to make a prognosis?
Would you reject/settle for the present prognosis? Why or why not? Determine three potential situations that could be thought-about as a differential prognosis for this affected person. Clarify your reasoning utilizing not less than three totally different references from present evidence-based literature.

Studying Assets

Required Readings (click on to develop/cut back)

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s information to bodily examination: An interprofessional strategy (ninth ed.). St. Louis, MO: Elsevier Mosby.

Chapter 6, “Very important Indicators and Ache Assessment”

This chapter describes the expertise of ache and its causes. The authors additionally describe the method of ache Assessment.

Chapter 18, “Stomach”

On this chapter, the authors summarize the anatomy and physiology of the stomach. The authors additionally clarify how you can conduct an Assessment of the stomach.

Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Advanced well being Assessment and scientific prognosis in main care (sixth ed.). St. Louis, MO: Elsevier Mosby.

Credit score Line: Advanced Health Assessment and Scientific Analysis in Main Care, sixth Version by Dains, J.E., Baumann, L. C., & Scheibel, P. Copyright 2019 by Mosby. Reprinted by permission of Mosby through the Copyright Clearance Middle.

Chapter three, “Belly Ache”

This chapter outlines how you can accumulate a targeted historical past on belly ache. That is adopted by what to search for in a bodily examination with the intention to make an correct prognosis.

Chapter 10, “Constipation”

The main focus of this chapter is on figuring out the causes of constipation via taking a targeted historical past, conducting bodily examinations, and performing laboratory checks.

Chapter 12, “Diarrhea”

On this chapter, the authors concentrate on diagnosing the reason for diarrhea. The chapter consists of inquiries to ask sufferers in regards to the situation, issues to search for in a bodily examination, and prompt laboratory or diagnostic research to carry out.

Chapter 29, “Rectal Ache, Itching, and Bleeding”

This chapter focuses on how you can diagnose rectal bleeding and ache. It features a desk containing potential diagnoses, the accompanying bodily indicators, and prompt diagnostic research.

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

Credit score Line: Advanced follow nursing procedures, 1st Version by Colyar, M. R. Copyright 2015 by F. A. Davis Firm. Reprinted by permission of F. A. Davis Firm through the Copyright Clearance Middle.

These sections under clarify the procedural information wanted to carry out gastrointestinal procedures.

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

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

Observe: Obtain this Pupil Guidelines and Stomach Key Factors to make use of throughout your follow belly examination.

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Stomach: Pupil guidelines. In Seidel’s information to bodily examination: An interprofessional strategy (ninth ed.). St. Louis, MO: Elsevier Mosby.

Credit score Line: Seidel’s Information to Bodily Examination, ninth Version 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 through the Copyright Clearance Middle.

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Stomach: Key factors. In Seidel’s information to bodily examination: An interprofessional strategy (ninth ed.). St. Louis, MO: Elsevier Mosby.

Credit score Line: Seidel’s Information to Bodily Examination, ninth Version 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 through the Copyright Clearance Middle.

Doc: Midterm Examination Assessment (Phrase doc)

Elective Useful 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 Stomach, Perineum, Anus, and Rectosigmoid” (pp. 445–527)

This chapter explores the well being Assessment processes for the stomach, perineum, anus, and rectosigmoid. This chapter additionally examines the signs of many situations in these areas.

Chapter 10, “The Urinary System” (pp. 528–540)

On this chapter, the authors present an summary of the physiology of the urinary system. The chapter additionally lists signs and situations of the urinary system.

Required Media (click on to develop/cut back)

On-line media for Seidel’s Information to Bodily Examination

It’s extremely really useful that you simply entry and view the sources included with the course textual content, Seidel’s Information to Bodily Examination. Give attention to the movies and animations in Chapter 17 that relate to the Assessment of the stomach and gastrointestinal system. Check with Week four for entry instruc
Advanced Health Assessment and Diagnostic Reasoning
Case Examine
Affected person Info:
Initials: JR Age: 47 Intercourse: Male Race: Caucasian
Subjective Knowledge
Chief Grievance: “My abdomen hurts! I’ve diarrhea, and nothing appears to Help.”
HPI: JR, 47 yo WM, with c/o of generalized acute belly ache for 3 days. Denies that he has taken drugs. He charges the belly ache is a 5/10 at the moment however at worst the ache has been a 9/10 in the course of the preliminary onset of the belly ache. He stories that he’s in a position to eat with some nausea afterward, denies vomiting.
Present Medicines: Lisinopril 10mg, Amlodipine 5 mg, Metformin 1000mg, Lantus 10 models qhs
Allergy symptoms: NKDA
PMHx: HTN, Diabetes, hx of GI bleed four years in the past

Soc Hx: Denies tobacco use; occasional ETOH, married, three kids (1 woman, 2 boys)
Fam Hx: No hx of colon most cancers, Father hx DMT2, HTN, Mom hx HTN, Hyperlipidemia, GERD
O.
VS: Temp 99.eight; BP 160/86; RR 16; P 92; HT 5’10”; WT 248lbs
Coronary heart: RRR, no murmurs
Lungs: CTA, chest wall symmetrical
Pores and skin: Intact with out lesions, no urticaria
Abd: tender, hyperactive bowel sounds, constructive ache within the LLQ on palpation
Diagnostics: None
1. Differential Diagnoses: LLQ belly ache: Gastroenteritis
Subjective Portion
The subjective portion reveals that the well being knowledge is throughout the optimum vary. The knowledge is backed up by the chief grievance about diarrhea. The affected person additionally complains of nausea and belly ache. He has taken no remedy but to alleviate the situation. The grievance means that the digestive system will not be functioning correctly. Moreover, the subjective portion reveals that the affected person has hypertension and diabetes and is at present on remedy. The hypertension can also be prompt by the remedy the affected person is at present taking. The affected person has no historical past of allergy symptoms, which might have triggered the an infection. Nonetheless, they’ve a historical past of a digestive tract downside which is gastrointestinal an infection. The information requires additional data to evaluate the situation critically.
Further Info
The extra data is critical for critically analyzing the state of affairs and diagnosing the issue. For instance, the chief grievance ought to point out the onset of nausea and diarrhea. The details about diarrhea needs to be accompanied by affirmation about whether or not there’s blood within the stool. The situation might have been triggered after taking particular meals at residence, lodge or in an occasion. The eating regimen of the affected person for the final three days must also be offered. The eating regimen can even reveal if the meals have been taking along with different folks and if they’re additionally at present exhibiting related signs. The affected person must also describe their way of life which shall be used to disclose the drinks they’d have taken that triggered a abdomen upset. Goal data must also seize whether or not the affected person has skilled extreme thirst. The extra data will present a chance to make an knowledgeable prognosis or suggest additional checks to be carried out (Dennly, 2019).

Goal Portion
The target portion reveals the present well being situation of the affected person particularly utilizing the important indicators. The physique temperature is regular, the situation of the lungs is wholesome in addition to the pores and skin. Nonetheless, the stomach has hyperactive bowel sounds which point out the opportunity of diarrhea, irregular bowel motion or constipation. The bowel sounds point out that it’s essential to get extra details about the digestive tract particularly via diagnostic checks akin to CT scan or X-rays (Dennehy, 2019). Moreover, the affected person has a hypertension of 160/86, however he takes the remedy. The burden of the affected person additionally reveals they could possibly be obese. The burden is a threat as a result of hypertension and diabetes the affected person is affected by. Due to this fact, though the affected person is complaining about nausea and diarrhea, it is very important refer them to a specialist who will verify the progress and threat components.
Further Info
The doc ought to embrace extra goal data to Help a clinician make an correct prognosis. As an illustration, the clinician ought to document the overall look of the affected person. Descriptions akin to alert and oriented, NAD, boring facial features, and hygiene shall be important within the prognosis. The overall data shall be used to explain if the affected person is comfy and unwell.
Subjective and Goal Info
The Assessment is partially supported by the subjective and goal data introduced within the documentation. The documentation is missing important data and thus the Assessment could also be inaccurate. The inaccuracy is because of different situations which will current related signs together with diarrhea and nausea (Wooden, 2018). The signs might be attributable to instances of meals poisoning. It is usually essential to know the meals the affected person took the final three days, the place they have been ready and the opposite individuals who ate the meals. You will need to reveal if the affected person has eaten meals or drinks that he doesn’t steadily take. The affected person ought to clarify additional the historical past of gastrointestinal bleeding 4 years in the past. The reason ought to elaborate if the situation has reoccurred and the circumstances surrounding the bleeding.
Further data can also be essential to Help rule out the situations that trigger related signs. The situations embrace inflammatory bowel illness, gastritis, viral an infection, meals poisoning, peptic ulcer, irritable bowel syndrome, and esophagitis. The situations shall be utilized in differential prognosis to slender down to at least one situation. The clinician thus requires extra subjective and goal data to Help make an correct prognosis and keep away from a potential misdiagnosis.
Diagnostic Exams
Diagnostic checks are essential to supply extra data to a clinician to Help them make a important prognosis. For instance, a pattern stool take a look at is critical to judge the virus or micro organism that could possibly be upsetting the digestive system. A stool take a look at is used to detect norovirus and rotavirus which might trigger signs just like gastroenteritis (Stanley, Moriarty & Cronin, 2016). The details about the viral or bacterial an infection will Help rule out different situations. The affected person may additionally require CT scans and sigmoidoscopy. The radiologic examination is used to look at the digestive tract and determine a potential inflammatory bowel illness. However, sigmoidoscopy shall be used to look at irregular cells alongside the digestive tract and ulcers since they trigger related signs akin to nausea and diarrhea (Stanley, Moriarty & Cronin, 2016). An endoscopy will also be carried out to verify the situation of the digestive tract. The main focus is on the digestive tract as a result of hyperactive bowel sounds that affirm the presence of irregular exercise within the bowels (Kelly, Liebenberg & Cohen, 2019). It is usually essential to take a blood take a look at to verify the presence of antibodies for gastrointestinal parasites (Kelly, Liebenberg & Cohen, 2019). The diagnostic checks shall be used to supply data that may affirm the present diagnostic outcomes of gastroenteritis or affirm one other well being situation.
Settle for or Reject Analysis
The present prognosis is unacceptable since important checks are but to be carried out. The Assessment was carried out with out adopting a complete strategy, particularly on the diagnostic checks. The affected person did additionally not present details about the meals taken, the place they have been taken and who else took the meals and their present well being situation. The diagnostic reasoning additionally didn’t contain differential Assessment to Help rule out situations that current related signs. However, sufferers with hyperactive bowel sounds will largely be affected by gastroenteritis (Dennly, 2019). Nonetheless, there are different ailments which have signs akin to nausea, belly ache, and diarrhea which the affected person is complaining about. Due to this fact, to keep away from any misdiagnosis extra data is required. For instance, a CT scan or different radiological checks are essential to verify the state of the digestive tract (Dennly, 2019). The function of a sophisticated nurse can also be to hold out superior checks and to make sure they slender down to at least one well being situation that the affected person is affected by.
Differential Analysis
Differential prognosis is critical to Help rule out situations which will current nearly related signs. The signs introduced by the affected person recommend that the digestive tract has an issue, both a viral or bacterial an infection (Stanley, Moriarty & Cronin, 2016). As an illustration, the hyperactive bowel sounds level to a potential downside with the digestive system. in keeping with Wooden (2018) is essential to distinguish the precise situation of the affected person from others with related signs by finishing up superior diagnostic checks. The three situations that shall be analyzed within the differential prognosis embrace irritable bowel syndrome, bowel obstruction, and infected bowel illness. The three situations current nearly related signs however with main variations (Dennehy, 2019). It’s the accountability of superior nurses to hold out an in-depth Assessment of a situation earlier than prescribing remedy.
• Irritable Bowel Syndrome (IBS) – Irritable bowel syndrome is a situation that impacts the digestive tract particularly the big intestines. Wooden (2018) states that the signs of the illness embrace belly ache, diarrhea, bloating, and cramping. Sufferers affected by irritable bowel syndrome have a traditional bowel motion. The illness is triggered by alcohol or dairy merchandise. You will need to perform blood, stool checks or gluten tolerance to diagnose the situation (Wooden, 2018). If the situation persists for 6-8weeks superior nurses might require to hold out proctosigmoidoscopy to look at the rectum.
• Bowel obstruction – Bowel obstruction is a illness that impacts the digestive tract inflicting varied signs akin to bloating, vomiting, and belly ache (Kelly, Liebenberg & Cohen, 2019). Sufferers may expertise lack of urge for food and problem in passing gasoline. The situation can happen to an individual of any age together with newborns and aged. It’s prevalent amongst individuals who had surgical procedure of the digestive system particularly gastrointestinal surgical procedure. It’s largely attributable to colon most cancers, hernia and infected gut (Kelly, Liebenberg & Cohen, 2019). The obstruction causes frequent vomiting. The obstruction could also be partial or full. The prognosis for the situation features a CT scan, MRI, and X-ray.
• Inflammatory bowel illness – The situation results in irritation of the digestion tract. The irritation causes lack of urge for food, diarrhea, and belly ache (Stanley, Moriarty & Cronin, 2016). The situation is an umbrella title for different ailments akin to Crohn and ulcerative colitis (Stanley, Moriarty & Cronin, 2016). Varied ailments may additionally trigger fever and anemia. The irritation causes injury to the interior layer of the big gut.

References
Dennehy, P. H. (2019). Infectious Gastroenteritis. Introduction to Scientific Infectious Illnesses (pp. 157-168). Springer, Cham.
Holtmann, G. J., Ford, A. C., & Talley, N. J. (2016). Pathophysiology of irritable bowel syndrome. The Lancet Gastroenterology & Hepatology, 1(2), 133-146.
Kelly, T., Liebenberg, P., & Cohen, A. (2019). A uncommon case report of small bowel obstruction following colonoscopy. Journal of Surgical Case Experiences, 2019(2), rjz049.
Stanley, E., Moriarty, H. Okay., & Cronin, C. G. (2016). Advanced multimodality imaging of inflammatory bowel illness in 2015: an replace. World Journal of Radiology, eight(6), 571.
Wooden, J. D. (2018). Neuropathophysiology of the irritable bowel syndrome. In Physiology of the Gastrointestinal Tract (pp. 1643-1668). Tutorial Press.

Order | Check Discount

Tags: Advanced health assessment and diagnostic reasoning