Walden University – NURS 6512 – Advanced Health Assessment head to toe

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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.

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Learning Objectives – Week 6: Assessment of the Abdomen and Gastrointestinal System

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

Learning Resources – Week 6: Assessment of the Abdomen and Gastrointestinal System

Note: To access this week’s required library resources, please click on the link to the Course Readings List, found in the Course Materials section of your Syllabus.

NURS 6512 – Advanced Health Assessment head to toe Required Readings

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015). Seidel’s guide to physical examination (8th ed.). St. Louis, MO: Elsevier Mosby.

    • Chapter 4, “Vital Signs and Pain Assessment” (pp. 50-63)This chapter describes the experience of pain and its causes. The authors also describe the process of pain assessment. NURS 6512 Week 6: Assessment of the Abdomen and Gastrointestinal System.
  • Chapter 17, “Abdomen” (pp. 370-415)In this chapter, the authors summarize the anatomy and physiology of the abdomen. The authors also explain how to conduct an assessment on the abdomen.

Click here to learn more on SOAP NOTES and Decision Trees.  What is a SOAP Note? Elements of a SOAP Note. Soap Note sample.  Learn How to Write A Good SOAP Note.  For all Soap Notes assignments, count on topnursingpapers.com soap note nursing writers.

Dains, J. E., Baumann, L. C., & Scheibel, P. (2016). Advanced health assessment and clinical diagnosis in primary care (5th ed.). St. Louis, MO: Elsevier Mosby.

    • Chapter 3, “Abdominal Pain” (pp. 11-32)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” (pp. 110-117)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” (pp. 133-147)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” (pp. 344-356)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.

Sullivan, D. D. (2019). Guide to clinical documentation (3rd ed.). Philadelphia, PA: F. A. Davis.

  • Chapter 10, “Admitting a Patient to the Hospital” (pp. 217-238)

Note: Download this Adult Examination Checklist and Abdomen Physical Exam Summary to use during your practice abdominal examination.

Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2011). Adult examination checklist: Guide for abdominal assessment. In Mosby’s guide to physical examination (7th ed.). St. Louis, MO: Elsevier Mosby.

This Adult Examination Checklist: Guide for Abdominal Assessment was published as a companion to Seidel’s guide to physical examination (8th ed.), by Ball, J. W., Dains, J. E., & Flynn, J. A. Copyright Elsevier (2015). From https://evolve.elsevier.com/

Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2011). Physical exam summary: Abdomen. In Mosby’s guide to physical examination (7th ed.). St. Louis, MO: Elsevier Mosby.

This Abdomen Physical Exam Summary was published as a companion to Seidel’s guide to physical examination (8th ed.), by Ball, J. W., Dains, J. E., & Flynn, J. A. Copyright Elsevier (2015). From https://evolve.elsevier.com/

University of Virginia. (n.d.). Introduction to radiology: An online interactive tutorial.  This website provides an introduction to radiology and imaging. For this week, focus on gastrointestinal radiology.

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NURS 6512 – Advanced Health Assessment head to toe Required Media

Online media for Seidel’s Guide to Physical Examination

NURS 6512 – Advanced Health Assessment head to toe

It is highly recommended that you access and view the resources included with the course text, Seidel’s Guide to Physical Examination. Focus on the videos and animations in Chapters 7, and 17 that relate to the assessment of the abdomen and gastrointestinal system. Refer to Week 4 for access instructions on https://evolve.elsevier.com/. NURS 6512 Week 6: Assessment of the Abdomen and Gastrointestinal System.

Optional Resources- Week 6: Assessment of the Abdomen and Gastrointestinal System

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. NURS 6512 Week 6: Assessment of the Abdomen and Gastrointestinal System.

A woman went to the emergency room for severe abdominal cramping. She was diagnosed with diverticulitis; however, as a precaution, the doctor ordered a CAT scan. The CAT 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 assignment, you will analyze a SOAP 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.

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, hyperctive bowel sounds, pos pain in the LLQ
  • Diagnostics: None
  • NURS 6512 Week 6: Assessment of the Abdomen and Gastrointestinal System

NURS 6512 – Advanced Health Assessment head to toe

ASSESSMENT:

  • Left lower quadrant pain
  • Gastroenteritis
  • PLAN: This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.

To prepare:

With regard to the SOAP 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 complete NURS 6512 – Advanced Health Assessment head to toe paper:

  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 3 different references from current evidence based literature.

By Day 7

This assignment is due.

Submission and Grading Information

Grading Criteria

To access your rubric:

Week 6 Assignment Rubric

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Submit your Week 6 Assignment draft and review the originality report.

Submit Your Assignment by Day 7

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Week 6 Assignment

This exam is a test of your knowledge in preparation for your certification exam. No outside resources including books, notes, websites, or any other type of resource are to be used to complete this exam. You are expected to comply with Walden University’s Code of Conduct.

This exam will be on topics covered in weeks 1, 2, 3, 4, 5, and 6. Prior to starting the exam, you should review all of your materials. This exam is timed with a limit of two hours for completion. When time is up, your exam will automatically submit.

Assignment 2 (Optional) Practice Assessment: Abdominal Examination

The causes of abdominal pain can be extremely varied due to the sheer number of structures, organs, and functions within the abdomen. If abdominal pain is caused by a life-threatening condition, then swift and accurate assessment is essential.

In preparation for the Head-to-Toe Physical Assessment Video due in Week 10, it is recommended that you practice performing an abdominal examination this week.

Note: This is an optional practice physical assessment. You do not have to capture a video of this assessment, as no submission is required.

To prepare:

  • Arrange an appropriate time and setting with your volunteer “patient” to perform an abdominal examination.
  • Download and review Adult Examination Checklist: Guide for Abdominal Assessment provided in this week’s Learning Resources.
  • To perform the examination, ensure that you have a stethoscope, a centimeter ruler, measuring tape, and marking pens to mark the areas of measurement for consistency in measuring. NURS 6512 Week 6: Assessment of the Abdomen and Gastrointestinal System.

To complete:

  • Perform the abdominal examination. Be sure to cover all of the areas listed in the checklist and to use the equipment appropriately.

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