Assessment 1: 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 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.”PHI: 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.MPH: NTH, Diabetes, h of GI bleed 4 years ago Medications: Eosinophilic 10mg, Am bloodiness 5 mg, Misinform 1000mg, Bantus 10 units qts Allergies: NEDA HF: No h of colon cancer, Father h DMT2, NTH, Mother h NTH, Hyperglycemia, HERD Social: Denies tobacco use; occasional etch, 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: ERR, no murmurs Lungs: CAT, chest wall symmetrical Skin: Intact without lesions, no urticaria Abe: soft, hyperactive bowel sounds, pews pain in the LL Diagnostics: None ASSESSMENT:Left lower quadrant pain Gastroenteritis PLAN: This section is not required for the assignments in this course (RUNS 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: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 3 different references from current evidence based literature.
MOI Worksheet The MOI report is an influential set of recommendations that is being used to shape nursing practice in the US now and in the future. The committee established four key messages about nursing:1.Nurses should practice to the full extent of their education and training.2.Nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression.3.Nurses should be full partners¬–with physicians and other health professionals–in redesigning health care in the United States.4.Effective workforce planning and policy making require better data collection and an improved information infrastructure.Each of these recommendations is affected by multiple factors at the organizational, local, state, and national levels. In turn, each message affects multiple systems. As we’ve learned, different aspects of healthcare interrelate with one another, and changing one can have an unexpected effect on “downstream” outcomes.For this worksheet, identify which of the four key messages you want to address, and answer the following questions:1. What key message did you choose? Why do you think the MOI chose to emphasize this particular message/what is its purported significance? 2.What are the factors that affect that message, for good or bad?On an organizational level? Local? State? National 3. Have you seen changes on this key message being pursued? If so, what are they and where? 4.What are the expected outcomes of those efforts? Do you think these will be accomplished? Why or why not? 5.What is one recommendation you would make to your organization to promote the key message you chose, and why?
