Assignment 4: Abdominal Discomfort Assessment

Assignment 4: Abdominal Discomfort Assessment

Assignment 4: Abdominal Discomfort Assessment

Permalink: 

Assignment 4

Assignment Instructions:

For this 4-5 pages assignment, you will conduct a focused health history and physical assessment based upon your Practice Experience work in Shadow Health. Particularly, you will complete a focused assessment on Esther, an elderly patient who is complaining of abdominal discomfort. Please submit your summary documentation in MS Word. Use the submission parameters and rubric below to guide you in completion of this written assignment. Assignment 4: Abdominal Discomfort Assessment

Submission Parameters:

For this written assignment, please use the following guidelines and criteria. Also, please refer to the rubric for point allocation and assignment expectations. The expected length of the paper is approximately 4-5 pages, which does not include the cover page and reference page(s).

Introduction (including purpose statement)
Focus of the assessment
Describe the focus of this particular assessment on the patient complaining of abdominal discomfort.
Subjective Component
Describe the ROS, PMH, and other relevant data in this section.
Objective Component
Describe the physical examination findings including techniques of examination
Documented evidence to support clinical reasoning
Describe the list of differential diagnoses
Plan of care
Describe the plan of care individualized to findings, life-span stage of development with culturally specific considerations for each focused area of assessment.
Conclusion
References (use primary and/or reliable electronic sources)

In regards to APA format, please use the following as a guide:

Include a cover page and running head (this is not part of the 4-5 pages limit)
Include transitions in your paper (i.e. headings or subheadings)
Use in-text references throughout the paper
Use double space, 12 point Times New Roman fonta
Apply appropriate spelling, grammar, and organization
Include a reference list (this is not part of the 4-5 pages limit)
Attempt to use primary sources only. That said, you may cite reliable electronic sources (i.e. NCSBN, AANP)

Competency

20

18 16 0
Points Earned

Focus of the Assessment is identified with Special Considerations including Documented Focused Health History

Documentation clearly shows student has completed a focused assessment with identified special considerations including a well-documented focused health history.

Documentation supports the student has completed the focused assessment with minimal identification of special concerns. The focused health history is documented.

Documentation supports the student has completed the focused assessment without identification of special concerns. The focused health history is documented and lacks depth and specificity of weekly topic.

Documentation supports the student attempted to complete the focused assessment without identification of special concerns. The focused health history is briefly documented and lacks depth and specificity of weekly topic. Assignment 4: Abdominal Discomfort Assessment

/20

20

18

16

0

Documented Physical Examination Findings including Techniques of Examination

Documentation clearly shows student has completed the physical examination and accurately describes the techniques of examination for the week.

Documentation supports the student has completed the physical examination and describes the techniques of examination for the week.

Documentation supports student completed some of the physical examination for the focused assessment of the week. Documentation is accurate but lacks depth.

No evidence that the student is applying read concepts of advanced focused physical assessment. Documentation lacks depth and may lack coherence for understandability of tasks completed in this week.

/20

20

18

16

0

Documented Evidence to Support Clinical Reasoning with External Course Resources

Discourse clearly shows the student has studied the topic and has given thought to the focused assessed topic and documentation for the week.

Discourse supports the student has studied the topic and has given thought to the focused assessment topic and documentation for the week.

Discourse supports student studied some of the topic for the focused assessment topic this week. Discourse is accurate but lacks depth.

No evidence that that student has read or studied the topic.
Discourse lacks depth. May be presented in a rambling manner.
Content is inaccurate &/or is unclear.

/20

20

18

16

0

Individualized Plan of Care Based Upon Clinical Findings

Accurately presents an individualized plan of care based upon clinical findings.

Presents an individualized plan of care based upon clinical findings. Some minor omissions are noted.

Presents a plan of care that is not individualized based upon the clinical findings.

A plan of care is not presented or the plan of care presented lacks demonstration of competency or is irrelevant to the clinical findings. Assignment 4: Abdominal Discomfort Assessment

/20

5

4

3

0

Developmentally and Culturally Specific

Accurately documents a developmentally and culturally specific assessment and plan of care for the selected patient.

Documents a developmentally and culturally specific assessment and plan of care.

Presents a developmentally and culturally specific assessment or plan of care and one or both are not based upon the selected patient.

A developmentally and culturally specific assessment and plan of care are not presented or based upon the selected patient’s findings.

/5

5

4

3

0

Demonstration of Compliance with Ethical and Legal Standards of Professional Nursing Practice

Compliance with the ethical and legal standards of professional nursing practice is explicitly stated in the documentation of the focused physical assessment.

Compliance with the ethical and legal standards of professional nursing practice is stated in the documentation.

Compliance with the ethical and legal standards of professional nursing practice is briefly implied in the documentation of the focused physical assessment or inaccuracies are evidenced in the written assessment.

Compliance with the ethical and legal standards of professional nursing practice is not included in the documentation of the focused physical assessment.

/5

10

9

8

0

Grammar, Spelling, and Punctuation APA Format

APA Format, grammar, punctuation and spelling is accurate with errors.

APA Format, grammar, punctuation and spelling is accurate with less than two types of errors.

APA Format, grammar, punctuation and spelling is accurate with five or fewer types of errors.

APA Format, grammar, punctuation and spelling is accurate with more than five types of errors.

/10

COMMENTS:

TOTAL:

/100

Focused Exam: Abdominal Pain Results | Turned In
Health Assess – Spring 1 2020, 322301
R eturn to Assignment (/assignments/289775/)

Your Results

Reopen (/assignment_attempts/6077725/reopen

Lab Pass (/assignment_attempts/6077725/lab_pass.p

O verview T ranscript

Objective Data Collection: 21 of 21 (100%)

S ubjective Data Collection

O bjective Data Collection

Correct
Partially correct

Incorrect Missed

E ducation & Empathy D ocumentation

Inspected head and face 1 of 1 point

C are Plan

Skull Symmetry (1/3 point)
Symmetric Asymmetric

Facial Feature Symmetry (1/3 point)
Symmetric Asymmetric

Appearance (1/3 point)
No visible abnormal findings Flushed appearance
Rash or lesion
Skin growths (freckles, moles, or birth mark) Excessive hair growth
Evidence of skin trauma (scar, laceration, or bruising)

Inspected nasal mucosa 1 of 1 point

Inspected mouth 1 of 1 point

Oral Mucosa (1/1 point)
Moist and pink Dry appearance Redness

Inspected abdomen 1 of 1 point

Symmetry (1/3 point)
Symmetric Asymmetric

Contour (1/3 point)
Flat
Rounded
Protuberant Hollowed

Appearance (1/3 point)
No visible abnormal findings Rash
Striae
https://www.coursehero.com/file/54630935B/Euslgthinegr-aPraoruknsd-Aubmdboilmicuinsal-Pain-ObjectiveData-Shadow-Healthpdf/

Distension
Visible masses (warts, cysts, or tumors) Freckles, birthmark, or discoloration
Excessive hair growth Scarring
Laceration, lesion, or wound Bruising
Redness Jaundice
Prominent veins

Inspected for edema in lower extremities 1 of 1 point

Right: Edema (1/4 point)
No edema Pitting
Non-pitting

Right: Severity Of Edema (1/4 point)
No edema
1+ Slight pitting
2+ Deeper pit, disappears in 10 to 15 seconds
3+ Noticeably deep pit that lasts more than a minute 4+ Very deep pit that lasts 2 to 5 minutes

Left: Edema (1/4 point)
No edema Pitting
Non-pitting

Left: Severity Of Edema (1/4 point)
No edema
1+ Slight pitting
2+ Deeper pit, disappears in 10 to 15 seconds
3+ Noticeably deep pit that lasts more than a minute 4+ Very deep pit that lasts 2 to 5 minutes

Auscultated heart sounds 1 of 1 point

Heart Sounds (1/2 point)
S1 and S2 audible
S1, S2, and S3 audible S1, S2, and S4 audible
S1, S2, S3, and S4 audible

Extra Heart Sounds (1/2 point)
No extra sounds Gallops
Murmur Friction rub Valve clicks

Auscultated breath sounds 1 of 1 point

Breath Sounds (1/3 point)
Present in all areas
Diminished in some areas Absent in some areas

Adventitious Sounds (1/3 point)
No adventitious sounds Wheezing
Fine crackles Stridor
Rhonchi Rales

Location (1/3 point)
All areas clear
Adventitious sounds in anterior right upper lobe Adventitious sounds in anterior right middle lobe Adventitious sounds in anterior right lower lobe Adventitious sounds in anterior left upper lobe
Adventitious sounds in anterior left lower lobe
Adventitious sounds in posterior right upper lobe Adventitious sounds in posterior right lower lobe Adventitious sounds in posterior left upper lobe Adventitious sounds in posterior left lower lobe

Auscultated abdominal aorta 1 of 1 point

https://www.coursehero.com/file/54630935/Esther-Parks-Abdominal-Pain-ObjectiveData-Shadow-Healthpdf/

Sound (1/1 point) Assignment 4: Abdominal Discomfort Assessment
No bruit Bruit

Auscultated bowel sounds 1 of 1 point

Bowel Sounds (1/2 point)
Absent
Hypoactive Normoactive Hyperactive

Location Of Non Normoactive Bowel Sounds (1/2 point)
All quadrants normoactive Right upper quadrant
Right lower quadrant Left upper quadrant Left lower quadrant

Auscultated abdominal arteries 1 of 1 point

Right: Renal (1/6 point)
No bruit Bruit

Right: Iliac (1/6 point)
No bruit Bruit

Right: Femoral (1/6 point)
No bruit Bruit

Left: Renal (1/6 point)
No bruit Bruit

Left: Iliac (1/6 point)
No bruit Bruit

Left: Femoral (1/6 point)
No bruit Bruit

Percussed abdomen 1 of 1 point

Observations (1/1 point)
All areas generally tympanic
Some areas dull, some tympanic Some areas resonant

Percussed CVA tenderness 1 of 1 point

Patient Reaction (1/1 point)
Did not react Pain reaction

Percussed spleen 1 of 1 point

Spleen (1/1 point)
Tympany Dullness

Percussed liver 1 of 1 point

Liver Span (1/1 point)
Smaller than 6 cm
Between 6 and 12 cm Greater than 12 cm

Palpated abdomen – light 1 of 1 point

Tenderness (1/3 point) Location Of Tenderness (1/3 point)

https://www.coursehero.com/file/54630935N/Eosnteherer-pPoarrtekds-Abdominal-Pain-ObjectiveData-Shadow-Healthpdf/

No quadrants tender

Tenderness reported

 

Observations (1/3 point) No additional observations Masses
Guarding Distension Right upper quadrant Right lower quadrant Left upper quadrant Left lower quadrant
Palpated abdomen – deep
1 of 1 point

Presence Of Unexpected Mass (1/2 point)
No palpable mass Palpable mass
Location Of Mass (1/2 point)
No palpable mass Right upper quadrant Right lower quadrant Left upper quadrant Left lower quadrant Around umbilicus
Palpated liver
1 of 1 point

Detection (1/1 point) Not palpable Palpable
Palpated spleen
1 of 1 point

Detection (1/1 point) Not palpable Palpable
Palpated bladder
1 of 1 point

Detection (1/1 point) Not palpable Palpable
Palpated kidneys
1 of 1 point

Right (1/2 point) Palpable Not palpable
Left (1/2 point) Palpable Not palpable
Tested skin turgor
1 of 1 point

Observations (1/1 point)
No tenting Tenting

© Shadow Health® 2012 – 2020
(800) 860-3241 | H elp Desk (https://support.shadowhealth.com/) | T erms of Service (/static/terms_of_service) | P rivacy Policy (/static/privacy_policy) | P atents (https://www.shadowhealth.com/patents)

35/Esther-Parks-Abdominal-Pain-ObjectiveData-Shadow-Healthpdf/ Assignment 4: Abdominal Discomfort Assessment