LAB ASSIGNMENT: ASSESSING THE ABDOMEN/NURS 6512
LAB ASSIGNMENT: ASSESSING THE ABDOMEN/NURS 6512
Assessing the Abdomen
Comprehensive patient assessment is crucial for accurate diagnoses and treatment of gastrointestinal problems. Nurses utilize subjective and objective data to understand a client’s prioritized and potential health needs. Therefore, this paper analyzes L.Z.’s case study. L.Z. presented to the hospital with an abdominal complaint.
Additional Subjective Information
Additional subjective data should be included in LZ’s documentation. Firstly, the nurse should seek more information about the factors associated with intermittent epigastric pain. The nurse should ask LZ for information such as the factors that precipitate or relieve his epigastric pain. The nurse should also seek information about the factors that relieve the epigastric pain. For example, pain relieved by drugs such as proton pump inhibitors would suggest peptic ulcer disease. The nurse should also document the subjective pain rating by the client. This will provide information about its severity. The nurse should also ask LZ if he has experienced a similar problem in the past and the interventions that were used to manage it (Lynn, 2022). A previous experience with the problem would prompt the nurse to order additional investigations to rule out potential pathologies.
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Information about the characteristics of the vomitus should also be obtained. This includes obtaining information related to the color and amount of the vomitus. Bloodstained vomitus would indicate a potential gastrointestinal bleeding. Information about previous use of non-steroidal anti-inflammatory (NSAIDs) should also be obtained. Prolonged use of (NSAIDs) anti- is associated with health risks such as peptic ulcer disease. Information about the impact of the problem on his functioning should also be obtained (Lynn, 2022). This includes determining if the problem affects his ability to function optimally and independently in his social and occupational roles.
Additional Objective Data
The nurse should obtain additional objective data in the documentation. Firstly, the nurse should have documented cardiovascular findings such as the presence or absence of peripheral edema, jugular venous distention, and abnormal chest movements with breathing. The presence of jugular venous distention could have indicated cardiovascular problems such as cardiac tamponade. Information on the presence of wheezes, crackles, stridor, and rhonchi should have been documented in the respiratory system. Findings such as wheezing would alert the nurse that the patient has airflow limitation. The assessment of the skin should have included information such as capillary refill, presence or absence of skin rashes, changes in skin pigmentation, and turgor. Poor skin turgor is associated with excessive fluid loss while hyperpigmentation is linked to conditions such as Addison’s disease. Abdominal assessment should include data on the presence or absence of organomegaly, ascites, or pulsations (Lynn, 2022). Findings such as abdominal pulsations on palpation would confirm abdominal aortic aneurysm.
Does Subjective and Objective Information support the Assessment?
Subjective and objective data support the assessment. There are several instances of subjective data in the case study. They include information about LZ’s chief complaint, history of his complaints, past medical history, current medications, allergies, and family and social history. Subjective information focuses on the patient’s experiences with his problems. The case study also has several examples of objective information. They include vital signs and findings of the heart, lungs, skin, and abdomen.
Diagnostic Tests that Would be Appropriate for the Case Study
Some diagnostic tests should be performed to develop LZ’s accurate diagnosis. Upper endoscopy should be performed to examine the stomach, esophagus, and the upper region of the small intestines. This will help rule out causes such as tumors and obstructions. The impedance PH testing should also be performed. This test measures esophageal PH over 24 hours. The results will be used to determine if LZ has nonacidic or acidic gastroesophageal reflux disease. A high-resolution esophageal manometry might also be required. Esophageal manometry will help the primary care provider assess food movement from the mouth to the stomach and detect any problems with muscles and nerves lining these structures. A barium swallow test might also be required. The test will allow the examination of the upper digestive tract for any structural abnormalities (Lynn, 2022). An ECG should also be performed to rule out cardiac problems such as myocardial infarction.
Rejecting or Accepting the Current Diagnosis
I will reject the current diagnosis of abdominal aortic aneurysm. An abdominal aortic aneurysm is a condition that is characterized by the enlargement of the abdominal aorta. Patients with abdominal aortic aneurysms experience symptoms such as severe abdominal or back pain, pulsation feeling in the abdomen, early satiety or vomiting, leg pain, and swelling. LZ has some of the symptoms of an abdominal aortic aneurysm such as vomiting. However, it does not qualify as a primary diagnosis because of the lack of cardinal symptoms such as abdominal pulsations and those associated with the cardiovascular system (Schanzer & Oderich, 2021). Therefore, I will reject the current diagnosis.
Three Possible Differential Diagnoses
One of LZ’s differential diagnoses is cholangitis. Cholangitis is a condition that develops due to infection of the bile ducts. The infection obstructs bile flow. Patients experience symptoms such as abdominal pain, fever, nausea, vomiting, and jaundice (Buxbaum et al., 2021). Cholangitis is the least likely cause of LZ’s problems because of the absence of symptoms such as fever and jaundice.
Acute cholecystitis is the other differential diagnosis that should be considered for LZ. Patients with acute cholecystitis experience symptoms that include right upper quadrant pain or epigastric pain that radiates to the scapula or the back. Patients also have tenderness in the right subcostal region and pain with increasing intensity. Murphy’s sign is also positive (Vagholkar, 2020). Acute cholecystitis is associated with risk factors such as being female, old age, family history of gallstones, and metabolic syndrome.
Myocardial infarction is the last differential diagnosis that should be considered in this case study. Myocardial infarction develops from coronary artery occlusion which impairs myocardial perfusion. Patients experience symptoms that include chest pain that radiates to the back, arms, jaw, neck, or shoulders. Patients describe the pain as aching, heavy, or pressure pain. The additional symptoms include fatigue, shortness of breath, nausea, sweating, restlessness, vomiting, and a feeling of impending doom (Alkhouli et al., 2021). Additional diagnostic investigations such as electrocardiography should be performed to rule out myocardial infarction.
Conclusion
Overall, the case study has inadequate subjective and objective information. I will add more subjective as well as objective data to the documentation. Subjective and objective data support the assessment. I would reject the current diagnosis based on the assessment findings. Diagnostic investigations should be done to assist in developing an accurate diagnosis.
References
Alkhouli, M., Alqahtani, F., Jneid, H., Al Hajji, M., Boubas, W., & Lerman, A. (2021). Age-Stratified Sex-Related Differences in the Incidence, Management, and Outcomes of Acute Myocardial Infarction. Mayo Clinic Proceedings, 96(2), 332–341. https://doi.org/10.1016/j.mayocp.2020.04.048
Buxbaum, J. L., Buitrago, C., Lee, A., Elmunzer, B. J., Riaz, A., Ceppa, E. P., Al-Haddad, M., Amateau, S. K., Calderwood, A. H., Fishman, D. S., Fujii-Lau, L. L., Jamil, L. H., Jue, T. L., Kwon, R. S., Law, J. K., Lee, J. K., Naveed, M., Pawa, S., Sawhney, M. S., … Wani, S. (2021). ASGE guideline on the management of cholangitis. Gastrointestinal Endoscopy, 94(2), 207-221.e14. https://doi.org/10.1016/j.gie.2020.12.032
Lynn, P. (2022). Taylor’s Clinical Nursing Skills. Lippincott Williams & Wilkins.
Schanzer, A., & Oderich, G. S. (2021). Management of Abdominal Aortic Aneurysms. New England Journal of Medicine, 385(18), 1690–1698. https://doi.org/10.1056/NEJMcp2108504
Vagholkar, Dr. K. (2020). Acute cholecystitis: Severity assessment and management. International Journal of Surgery Science, 4(2), 299–302. https://doi.org/10.33545/surgery.2020.v4.i2e.433
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
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:
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.
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.
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.
ABDOMINAL ASSESSMENT> Please write this up as a narrative so that you are able to correctly explain your analysis
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:
Abdominal Aortic Aneurysm (AAA)
Perforated Ulcer
Pancreatitis