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[SOLVED] CC: My stomach hurts I have diarrhea and nothing seems to help

CC: “My stomach hurts, I have diarrhea and nothing seems to help.”

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

PLAN: This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.

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.

REQUIRED READINGS:

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)

Note: Download this Student Checklist and Abdomen Key Points to use during your practice abdominal examination.

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Abdomen: Student checklist. 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.

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.

Expert Answer and Explanation

Abdominal Assessment

Assessment is a critical practice in nursing. Nursing assessment can be used to determine the current and future care needs of a patient (Ball, Dains, Flynn, Solomon & Stewart, 2019). Nursing assessment includes the recognition of abnormal versus normal physiology. The purpose of this assignment is to analyze the provided Episodic Note case study that describes abnormal findings in patients seen in a clinical setting and answer the provided questions.

Additional Subjective Data to be included in the Documentation

A lot of information was included in a subjective portion of the note. However, I feel that some critical data that can improve the assessment process are missing. For instance, the patient’s ethnic group was not mentioned. Some diseases are more prone in certain ethnic groups compared to others. Hence, identifying the race of the patient can help a nurse identify whether the client’s ethnicity is a risk factor for specific diseases. Another important data that should be added in the subjective portion of the note is the review of systems. The review of systems is the process of reviewing a patient’s body systems by asking them a series of questions to identify symptoms the client may be experiencing (Dains, Baumann & Scheibel, 2019).

The nurse who prepared this note did not review JR’s body systems and hence failed to identify any abnormalities with the systems. Information about immunizations should also be included in the subjective part. This information can help a nurse determine whether the patient is exposed to communicable diseases. The last information that should be included in the subjective part is the patient’s hobbies, what they like to do when free, whether they go to church and activities of daily living.

Additional Objective Data to be included in the Documentation

Objective data included in the assigned note can be used to determine a diagnosis. However, the following information should be added to the objective portion to make it unique and comprehensive. First, the general appearance of the patient should be added. Here, the nurse should describe whether the patient is alert, oriented, has acute distress, and answers questions properly (Ball et al., 2019). The general appearance of the patient can help a nurse determine the severity of their health complaints. Second, the nurse would have noted whether the pulse was normal or not. Description of the pulse rate can help rule out any cardiovascular abnormality. Third, the nurse could have included an assessment of the patient’s cardiovascular and respiratory.

Dains et al. (2019) note that nurses should always assess patients’ cardiovascular and respiratory systems when conducting the nursing assessment process. When assessing the cardiovascular system, the nurse should assess heart sounds, S1, and S2. On the other hand, when assessing the respiratory system, the nurse should describe the chest walls, respiratory rhythm, and lung condition. Additionally, when taking vital signs, information about the rate of PO2 under room air should be included in the objective data. Lastly, information about diagnostic tests and results should be included in the objective portion. Diagnostic tests can help a nurse make the appropriate decision when determining the disease ailing the patient. Without diagnostic tests and results, the nurse is likely to make an inaccurate diagnosis, and this can lead to medical errors.

Justification of the Assessment

Nurses should rely on subjective and objective data when deciding the health condition affecting the patient. The assessments for the case study include left lower quadrant pain and gastroenteritis. In my opinion, the charge nurse used the subjective data and some portion of the objective information to produce the assessment. Some of the symptoms of left lower quadrant pain include constipation, gas, diarrhea, indigestion, nausea, abdominal cramping or swelling, and blood in the stool (Dains et al., 2019). In the subjective data, the patient mentioned that she feels abdominal pain, diarrhea, and nausea. The nurse used the information to identify the first two diagnoses. Physical examination of the abdomen can also be used to decide on the disease ailing the patient. The nurse assessed the abdomen and found that it is soft, has hyperactive bowel sounds, and pos pain was seen in the LLQ. However, the nurse should have also made the provided assessment basing their decision on the diagnostic test results for more accuracy. On the contrary, there were no diagnostic tests done on the patient, and hence my decision that part of the objective data was used to support the assessment.

Appropriate Diagnostic Tests for the Case and How they can be used to make Diagnosis

Three diagnostic tests can be ordered by the doctor to find the disease ailing the patient. The first test is the blood test. Colyar (2015) notes that a complete blood count (CBC) test can help identify an infection in a patient’s body. The result of the blood test will help in determining whether the patient in the case has an infection. The type of infection can be determined by performing a culture and sensitivity. Overall, blood test results will be used to determine whether the patient has an infection and the type of infection affecting the client. The second test is urinalysis. This test is usually done to find whether infection or blood is present in the patient’s urinary tract (Ball et al., 2019). Urinary tract infection can pain in the uterus, kidneys, urethra, bladder, and as a result, lead to abdominal or back pain. Hence, the results of the test can be used to rule out UTI infection. The last test is a stool test. This test can be used to find blood in the stool. If the results show that the stool has blood that cannot be seen by naked eyes, then the patient has a problem with the upper digestive tract, a disease that can cause abdominal pain.

Diagnoses

I would accept the current diagnosis due to the following reasons. First, the patient noted that she has been feeling abdominal pain for three days. She also reported the feeling of nausea and diarrhea (Mian et al., 2018). All these symptoms are signs of left lower quadrant pain making the disease a possible diagnosis. Gastroenteritis symptoms include vomiting, watery diarrhea, stomach pain, headache, fever, cramping, and nausea (Patel & Kinsella, 2017). The patient reported diarrhea, stomach pain, abdominal pain, and nausea, and that is why I accepted the diagnosis. Apart from the two diagnoses, the following are the other three diseases that can be included in the differential diagnosis. The first disease is right lower quadrant pain. Some of the symptoms of the disease include nausea and abdominal pain, which have been reported by the patient (Mian et al., 2018). The second diagnosis is inflammatory bowel disease. The symptoms of the disease include fatigue, diarrhea, abdominal pain, and blood in the stool (Sahami et al., 2017). The third diagnosis is urinary tract infection site not specified. This disease has been included in the diagnosis because it causes abdominal pain (Clouse, 2018).

Conclusion

The nurse could have included the review of systems, the patient’s race, and hobbies in the subjective portion. The diagnostic test results and general appearance should have been included in the objective portion. Apart from the two diagnoses, the patient might be suffering from UTI site not specified, inflammatory bowel disease, or right lower quadrant pain.

References

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.

Clouse, M. K. (2018). Evidence-driven Diagnosis and Treatment of Acute Urinary Tract Infections in Long-term Care. https://repository.belmont.edu/dnpscholarlyprojects/9/

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

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.

Mian, M., Khosa, F., Ali, I. T., McLaughlin, P., Klass, D., Chang, S., & Nicolaou, S. (2018). Faster magnetic resonance imaging in emergency room patients with right lower quadrant pain and suspected acute appendicitis. Polish journal of radiology, 83, e340. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6323540/

Patel, D. R., & Kinsella, E. (2017). Evaluation and management of lower back pain in young athletes. Translational pediatrics, 6(3), 225. doi: 10.21037/tp.2017.06.01

Sahami, S., Konté, K., Buskens, C. J., Tanis, P. J., Löwenberg, M., Ponsioen, C. J., … & D’Haens, G. R. (2017). Risk factors for proximal disease extension and colectomy in left-sided ulcerative colitis. United European gastroenterology journal, 5(4), 554-562. https://doi.org/10.1177%2F2050640616679552

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