NURS 6512 Week 6 Assignment 1: Assessment Midterm Test and Soap Note Analysis

NURS 6512 Week 6 Assignment 1: Assessment Midterm Test and Soap Note Analysis

NURS 6512 Week 6 Assignment 1: Assessment Midterm Test and Soap Note Analysis

Remember that Week 6 is next week and it is your midterm exam!! 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 2 hours for completion. When time is up, your exam will automatically submit. Take time to go through each modules objectives and make a study guide from them. Read all the assigned readings and review the content in each module. The test is around 100 questions long so be prepared to go once started.

ORDER A CUSTOMIZED, PLAGIARISM-FREE PAPER HERE

Good News For Our New customers . We can write this assignment for you and pay after Delivery. Our Top -rated medical writers will comprehensively review instructions , synthesis external evidence sources(Scholarly) and customize a quality assignment for you. We will also attach a copy of plagiarism report alongside and AI report. Feel free to chat Us

Due by Day 7 of Week 6

Abdominal Assessment Lab Assignment:

By Day 1 of Week 6

Welcome to Week 6. This week, your students will complete an analysis of the SOAP note provided. You can even write this up as a narrative so that you are able to correctly explain your analysis.

In this Assessment 1 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 identify three possible conditions that may be considered as a differenial diagnosis for this patient.

ABDOMINAL ASSESSMENT

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

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

LAB ASSIGNMENT: ASSESSING THE ABDOMEN

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

RESOURCES

Be sure to review the Learning Resources before completing this activity.

Click the weekly resources link to access the resources.

WEEKLY RESOURCES

LEARNING RESOURCES

Required Readings

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2023). Seidel’s guide to physical examination: An interprofessional approach (10th ed.). St. Louis, MO: Elsevier Mosby.

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 Download 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”Download 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”Download 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”Download 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 115, “X-Ray Interpretation of Abdomen” Download “X-Ray Interpretation of Abdomen”(pp. 514–520)

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

Document: Midterm Exam Review Download Midterm Exam Review(Word document)

Required Media

Assessment of the Abdomen and Gastrointestinal System – Week 6 (14m)

Online media for Seidel’s Guide to Physical Examination

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 Chapter 17 that relate to the assessment of the abdomen and gastrointestinal system. Refer to Week 4 for access instructions on https://evolve.elsevier.com/Links to an external site.

Optional Resources

LeBlond, R. F., Brown, D. D., & DeGowin, R. L. (2020). DeGowin’s diagnostic examination (11th ed.). New York, NY: McGraw Hill Medical.

Chapter 9, “The Abdomen, Perineum, Anus, and Rectosigmoid”

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”

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.

Chabok, A., Thorisson, A., Nikberg, M., Schultz, J. K., & Sallinen, V. (2021). Changing paradigms in the management of acute uncomplicated diverticulitisLinks to an external site.. Scandinavian Journal of Surgery, 110(2), 180–186. https://doi.org/10.1177/14574969211011032

Hussein, A., Arena, A., Yu, C., Cirilli, A., & Kurkowski, E. (2021). Abdominal pain in the elderly patient: Point-of-care ultrasound diagnosis of small bowel obstructionLinks to an external site.. Clinical Practice and Cases in Emergency Medicine, 5(1), 127–128. https://doi.org/10.5811/cpcem.2020.11.50029

TO PREPARE

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.

THE ASSIGNMENT

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.

BY DAY 7 OF WEEK 6

Submit your Lab Assignment.

SUBMISSION INFORMATION

Before submitting your final assignment, you can check your draft for authenticity. To check your draft, access the Turnitin Drafts from the Start Here area.

To submit your completed assignment, save your Assignment as WK6Assgn1+last name+first initial.

Then, click on Start Assignment near the top of the page.

Next, click on Upload File and select Submit Assignment for review.

Rubric

NURS_6512_Week_6_Assignment_1_Rubric

NURS_6512_Week_6_Assignment_1_Rubric

Criteria Ratings Pts

This criterion is linked to a Learning OutcomeWith regard to the SOAP note case study provided, address the following:Analyze the subjective portion of the note. List additional information that should be included in the documentation.

12 to >9.0 pts

Excellent

The response clearly, accurately, and thoroughly analyzes the subjective portion of the SOAP note and lists detailed additional information to be included in the documentation.

9 to >6.0 pts

Good

The response accurately analyzes the subjective portion of the SOAP note and lists additional information to be included in the documentation.

6 to >3.0 pts

Fair

The response vaguely and/or with some inaccuracy analyzes the subjective portion of the SOAP note and vaguely and/or with some inaccuracy lists additional information to be included in the documentation.

3 to >0 pts

Poor

The response inaccurately analyzes or is missing analysis of the subjective portion of the SOAP note, with inaccurate and/or missing additional information included in the documentation.
12 pts

This criterion is linked to a Learning OutcomeAnalyze the objective portion of the note. List additional information that should be included in the documentation.

12 to >9.0 pts

Excellent

The response clearly, accurately, and thoroughly analyzes the objective portion of the SOAP note and lists detailed additional information to be included in the documentation.

9 to >6.0 pts

Good

The response accurately analyzes the objective portion of the SOAP note and lists additional information to be included in the documentation.

6 to >3.0 pts

Fair

The response vaguely and/or with some inaccuracy analyzes the objective portion of the SOAP note and vaguely and/or inaccurately lists additional information to be included in the documentation.

3 to >0 pts

Poor

The response inaccurately analyzes or is missing analysis of the objective portion of the SOAP note, with inaccurate and/or missing additional information included in the documentation.
12 pts

This criterion is linked to a Learning OutcomeIs the assessment supported by the subjective and objective information? Why or why not?
16 to >13.0 pts

Excellent

The response clearly and accurately identifies whether or not the assessment is supported by the subjective and/or objective information, with a thorough and detailed explanation.

13 to >10.0 pts

Good

The response accurately identifies whether or not the assessment is supported by the subjective and/or objective information, with an explanation.

10 to >7.0 pts

Fair

The response vaguely and/or inaccurately identifies whether or not the assessment is supported by the subjective and/or objective information, with a vague explanation.

7 to >0 pts

Poor

The response inaccurately identifies whether or not the assessment is supported by the subjective and/or objective information, with an inaccurate or missing explanation.
16 pts

This criterion is linked to a Learning OutcomeWhat diagnostic tests would be appropriate for this case, and how would the results be used to make a diagnosis?
20 to >17.0 pts

Excellent

The response thoroughly and accurately describes appropriate diagnostic tests for the case and explains clearly, thoroughly, and accurately how the test results would be used to make a diagnosis.

17 to >14.0 pts

Good

The response accurately describes appropriate diagnostic tests for the case and explains clearly and accurately how the test results would be used to make a diagnosis.

14 to >11.0 pts

Fair

The response vaguely and/or with some inaccuracy describes appropriate diagnostic tests for the case and vaguely and/or with some inaccuracy explains how the test results would be used to make a diagnosis.

11 to >0 pts

Poor

The response inaccurately describes appropriate diagnostic tests for the case, with an inaccurate or missing explanation of how the test results would be used to make a diagnosis.
20 pts

This criterion is linked to a Learning Outcome· Would you reject or accept the current diagnosis? Why or why not?· Identify three possible conditions that may be considered as a differenial diagnosis for this patient. Explain your reasoning using at least three different references from current evidence-based literature.

25 to >22.0 pts

Excellent

The response states clearly whether to accept or reject the current diagnosis, with a thorough, accurate, and detailed explanation of sound reasoning. The response clearly, thoroughly, and accurately identifies three conditions as a differential diagnosis, with reasoning that is explained clearly, accurately, and thoroughly using at least three different references from current evidence-based literature.

22 to >19.0 pts

Good

The response states whether to accept or reject the current diagnosis, with an accurate explanation of sound reasoning. The response accurately identifies three conditions as a differential diagnosis, with reasoning that is explained accurately using three different references from current evidence-based literature.

19 to >16.0 pts

Fair

The response states whether to accept or reject the current diagnosis, with a vague explanation of the reasoning. The response identifies two or three conditions as a differential diagnosis, with reasoning that is explained vaguely and/or inaccurately using three references from current evidence-based literature.

16 to >0 pts

Poor

The response inaccurately or is missing a statement of whether to accept or reject the current diagnosis, with an explanation that is inaccurate and/or missing. The response identifies two or fewer conditions as a differential diagnosis, with reasoning that is missing or explained inaccurately using three or fewer references from current evidence-based literature.
25 pts

This criterion is linked to a Learning OutcomeWritten Expression and Formatting – Paragraph Development and Organization: Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused–neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria.

5 to >4.0 pts

Excellent

Paragraphs and sentences follow writing standards for flow, continuity, and clarity. A clear and comprehensive purpose statement, introduction, and conclusion are provided that delineate all required criteria.

4 to >3.0 pts

Good

Paragraphs and sentences follow writing standards for flow, continuity, and clarity 80% of the time. Purpose, introduction, and conclusion of the assignment are stated, yet are brief and not descriptive.

3 to >2.0 pts

Fair

Paragraphs and sentences follow writing standards for flow, continuity, and clarity 60%–79% of the time. Purpose, introduction, and conclusion of the assignment are vague or off topic.

2 to >0 pts

Poor

Paragraphs and sentences follow writing standards for flow, continuity, and clarity < 60% of the time. No purpose statement, introduction, or conclusion were provided.
5 pts

This criterion is linked to a Learning OutcomeWritten Expression and Formatting – English writing standards: Correct grammar, mechanics, and proper punctuation

5 to >4.0 pts

Excellent

Uses correct grammar, spelling, and punctuation with no errors.

4 to >3.0 pts

Good

Contains a few (1 or 2) grammar, spelling, and punctuation errors.

3 to >2.0 pts

Fair

Contains several (3 or 4) grammar, spelling, and punctuation errors.

2 to >0 pts

Poor

Contains many (≥ 5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding.
5 pts

This criterion is linked to a Learning OutcomeWritten Expression and Formatting – The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, running heads, parenthetical/in-text citations, and reference list.

5 to >4.0 pts

Excellent

Uses correct APA format with no errors.

4 to >3.0 pts

Good

Contains a few (1 or 2) APA format errors.

3 to >2.0 pts

Fair

Contains several (3 or 4) APA format errors.

2 to >0 pts

Poor

Contains many (≥ 5) APA format errors.
5 pts

Total Points: 100