Episodic Note Case Study:

Assessment of the Abdomen and Gastrointestinal System 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. 

Assignment: Assessing the Abdomen

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.

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

To Prepare

Review the Episodic note case study your instructor provides you for this week’s Assignment. 

· With regard to the Episodic note case study provided:

o Review this week’s Learning Resources, and consider the insights they provide about the case study.

o Consider what history would be necessary to collect from the patient in the case study.

o 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?

o Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.

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.

Resource for 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.

• 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.

Document: Midterm Exam Review (Word document)

Optional 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 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.

 

•  Adverse Event or Near Miss Analysis
     
•   
      
• Details
• Attempt 1Evaluated
• Attempt 2Available
• Attempt 3NotAvailable
• Toggle Drawer  Overview
      
  Write a 5–7-page a comprehensive analysis on an adverse event or  near miss from your professional nursing experience. Integrate research  and data on the event and use as a basis to propose a quality  improvement (QI) initiative in your current organization.
  Health care organizations strive for a culture of safety. Yet  despite technological advances, quality care initiatives, oversight,  ongoing education and training, laws, legislation and regulations,  medical errors continue to occur. Some are small and easily remedied  with the patient unaware of the infraction. Others can be catastrophic  and irreversible, altering the lives of patients and their caregivers  and unleashing massive reforms and costly litigation.
  Show More
     
• Toggle Drawer  Context
      The purpose of the report is to assess whether specific quality  indicators point to improved patient safety, quality of care, cost and  efficiency goals, and other desired metrics. Nurses and other health  professionals with specializations and/or interest in the condition,  disease, or the selected issue are your target audience.
     
• Toggle Drawer  Questions to Consider
      As you prepare to complete this assessment, you may want to think  about other related issues to deepen your understanding or broaden your  viewpoint. You are encouraged to consider the questions below and  discuss them with a fellow learner, a work associate, an interested  friend, or a member of your professional community. Note that these  questions are for your own development and exploration and do not need  to be completed or submitted as part of your assessment.
  Show More    
• Toggle Drawer  Resources
      Required Resources
  MSN Program Journey
  The following is a useful map that will guide you as you continue  your MSN program. This map gives you an overview of all the steps  required to prepare for your practicum and to complete your degree. It  also outlines the support that will be available to you along the way.
   
• MSN Program Journey | Transcript.
• Show More    
•  Assessment Instructions
      Preparation
  Prepare a comprehensive analysis on an adverse event or near-miss  from your professional nursing experience that you or a peer  experienced. Integrate research and data on the event and use as a basis  to propose a Quality Improvement (QI) initiative in your current  organization.
  Note: Remember, you can submit all, or a portion  of, your draft to Smarthinking for feedback, before you submit the final  version of your analysis for this assessment. However, be mindful of  the turnaround time for receiving feedback, if you plan on using this  free service.
  The numbered points below correspond to grading criteria in the  scoring guide. The bullets below each grading criterion further  delineate tasks to fulfill the assessment requirements. Be sure that  your Adverse Event or Near-miss Analysis addresses all of the content  below. You may also want to read the scoring guide to better understand  the performance levels that relate to each grading criterion.
   

1. Analyze the missed steps or protocol deviations related to an adverse event or near miss.      
   • Describe how the event resulted from a patient’s medical management rather than from the underlying condition.
   • Identify and evaluate the missed steps or protocol deviations that led to the event.
   • Discuss the extent to which the incident was preventable.
   • Research the impact of the same type of adverse event or near miss in other facilities.
2. Analyze the implications of the adverse event or near miss for all stakeholders.      
   • Evaluate both short-term and long-term effects on the  stakeholders (patient, family, interprofessional team, facility,  community). Analyze how it was managed and who was involved.
   • Analyze the responsibilities and actions of the  interprofessional team. Explain what measures should have been taken and  identify the responsible parties or roles.
   • Describe any change to process or protocol implemented after the incident.
3. Evaluate quality improvement technologies related to the event that are required to reduce risk and increase patient safety.      
   • Analyze the quality improvement technologies that were put in  place to increase patient safety and prevent a repeat of similar events.
   • Determine whether the technologies are being utilized appropriately.
   • Explore how other institutions integrated solutions to prevent these types of events.
4. Incorporate relevant metrics of the adverse event or near miss incident to support need for improvement.      
   • Identify the salient data that is associated with the adverse  event or near miss that is generated from the facility’s dashboard. (By  dashboard, we mean the data that is generated from the information  technology platform that provides integrated operational, financial,  clinical, and patient safety data for health care management.)
   • Analyze what the relevant metrics show.
   • Explain research or data related to the adverse event or near  miss that is available outside of your institution. Compare internal  data to external data.
5. Outline a quality improvement initiative to prevent a future adverse event or near miss.      
   • Explain how the process or protocol is now managed and monitored in your facility.
   • Evaluate how other institutions addressed similar incidents or events.
   • Analyze QI initiatives developed to prevent similar incidents,  and explain why they are successful. Provide evidence of their success.
   • Propose solutions for your selected institution that can be implemented to prevent future adverse events or near-miss incidents.
6. Communicate analysis and proposed initiative in a professional  and effective manner, writing content clearly and logically with correct  use of grammar, punctuation, and spelling.
7. Integrate relevant sources to support arguments, correctly formatting citations and references using current APA style.
8. Submission Requirements
    

• Length of submission: A minimum of five but no more than seven double-spaced, typed pages.
• Number of references: Cite a minimum of three sources (no older  than seven years, unless seminal work) of scholarly or professional  evidence that support your evaluation, recommendations, and plans.
• APA formatting: Resources and citations are formatted according to current APA style and formatting.

 

Theories of successful aging explain factors that support individuals as they grow old, contributing to their ability to function. Increasing your understanding of factors that support successful aging improves your ability to address the needs of elderly clients and their families.

To prepare for this Discussion, review this week’s media. In addition, select a theory of successful aging to apply to Sara’s case.

Parker Family Episode 2 Program Transcript PARKER: Ever since my husband died, there’s been no one to talk to. It’s just, really, no one. And when Stephanie is home, I just feel so alone. FEMALE SPEAKER: What about the day center you go to? Isn’t that helping? PARKER: I don’t like it. What makes me really feel good, though, is when I go shopping, buying things. And my kittens. I love my cats. Oh, have you seen them? I have pictures. Just take a look. Look! These are so cute. My babies. FEMALE SPEAKER: Yes, they’re very cute. And wow, you have a lot of them.  PARKER: Oh, well, it’s their home, too, not just Princess Stephanie’s.  FEMALE SPEAKER: The day program you’re attending, are you seeing a  psychiatrist there?  PARKER: Yes. Dr. Lewin.  FEMALE SPEAKER: May I ask how that’s going?  PARKER: He says that I’m depressed.  FEMALE SPEAKER: In the pictures you showed me, you just talked about the  cats, but I also saw all the things you keep around you, the hoarding. I understand how depressed you been since your husband passed away. How alone you’ve felt. [SIGH] But I would like us to try and set up a plan to begin to address the hoarding. It’s very clear that that’s one of the big issues that’s affecting your relationship with Stephanie and your life together. Can we try that? PARKER: I don’t like it when we fight. She’s still my baby, too. Yes, I want to try.  

References to use

 

Clark, E. (2018). Loss and suffering: The role of social work. Retrieved from

http://www.socialworker.com/feature-articles/practice/loss-and-suffering-the-role-of-social-work/

Fisher, C. (2018). Counseling connoisseur: Children and grief. Retrieved from

https://ct.counseling.org/2018/11/counseling-connoisseur-children-and-grief/

Zoll, L. (n.d.). A grief trajectory. Retrieved from https://www.socialworktoday.com/news/pp_063017_5.shtml

By Day 3

Post a Discussion in which you:

• Explain key life events that have influenced Sara’s relationships. Be sure to substantiate what makes them key in your perspective.
• Explain how you, as Sara’s social worker, might apply a theory of successful aging to her case. Be sure to provide support for your strategy.

 

Assignment 1: “Captain of the Ship” Project – Obsessive-Compulsive Disorders

In earlier weeks, you were introduced to the concept of the “captain of the ship.” In this Assignment, you become the “captain of the ship” as you provide treatment recommendations and identify medical management, community support resources, and follow-up plans for a client with an obsessive-compulsive disorder.

Students will:

• Recommend psychopharmacologic treatments based on therapeutic endpoints for clients with obsessive-compulsive disorders
• Recommend psychotherapy based on therapeutic endpoints for clients with obsessive-compulsive disorders
• Identify medical management needs for clients with obsessive-compulsive disorders
• Identify community support resources for clients with obsessive-compulsive disorders
• Recommend follow-up plans for clients with depression disorders

To prepare for this Assignment:

• Select an adult or older adult client with an obsessive-compulsive disorder you have seen in your practicum.

In 3–4 pages, write a treatment plan for your client in which you do the following:

• Describe the HPI and clinical impression for the client.
• Recommend psychopharmacologic treatments and describe specific and therapeutic endpoints for your psychopharmacologic agent. (This should relate to HPI and clinical impression.)
• Recommend psychotherapy choices (individual, family, and group) and specific therapeutic endpoints for your choices.
• Identify medical management needs, including primary care needs, specific to this client.
• Identify community support resources (housing, socioeconomic needs, etc.) and community agencies that are available to assist the client.
• Recommend a plan for follow-up intensity and frequency and collaboration with other providers.

You now have an idea of the role of the APRN, and legal/professional issues in prescribing. As a future nurse practitioner, you have the authority, based on your state nurse practice act, to prescribe medications for the patients for whom you will provide care, and the responsibility of prescriptive authority is more than just simply writing a prescription correctly. 

 

Support all posts with at least 2 cited peer review references within 5 years of publication (references cannot be older than 5 years).

 All posts are to be written in APA 6th edition format as required by the university.