NURS 6512 Assignment 1: Lab Assignment: Assessing the Abdomen Subjective Portion Analysis

NURS 6512 Assignment 1: Lab Assignment: Assessing the Abdomen Subjective Portion Analysis

Appropriate clinical diagnosis and the development of personalized treatment plans for specific patients need a rigorous healthcare assessment. As such, more information on the nature of patient LZ’s pain is needed.  What are the characteristics and severity of the client’s pain? What triggered the onset of the pain? Was it a progressive pain, or did he suddenly feel the effects of the pain? This necessitates a thorough examination of the patient’s symptoms to determine what kind of pain he is experiencing (Ball et al., 2017). It is important for the practitioner to get further information about the conditions that have caused the pain to increase or intensify. Other questions that a clinician should ask include: How would you rate your current level of pain? What is the highest number on a scale of one to ten? Is there any medicine you’ve taken in the last week? Have you had any surgical procedures performed on you? Do you experience greater pain when you are lying down than when you are sitting upright?

Objective Portion Analysis

There are critical things missing from the soap note when it comes to the objective information. The overall appearance of the client must be described in the objective component of the note.  It is also necessary to record the patient’s level of consciousness. The findings of any laboratory tests performed, such as abdominal ultrasound and CT scan should be documented. Apart from the vital signs, heart, lungs, skin, and abdomen evaluation, the practitioner should additionally incorporate the client’s facial expression while assessing his painful area, the color of his skin, abdominal bloating, and whether or not he has excessive sweating.

Is the assessment supported by subjective and objective information?

The assessment is supported by the subjective and objective data. The patient has a history of abdominal pain that has become more severe over time, and he has also vomited. Furthermore, he reports pain in the epigastric region and guarding, which is in line with abdominal pain. Diagnostic tests such as the ultrasound and CT scan might provide additional findings to validate the assessment.

 Appropriate Diagnostic Tests

In order to determine the presence of infection and bleeding, a complete blood count will be required. Amylase and

NURS 6512 Assignment 1 Lab Assignment Assessing the Abdomen

lipase tests are also required since a high lipase level in the presence of a normal amylase level indicates that pancreatitis is unlikely to be the cause. Abdominal ultrasonography is the most often used diagnostic to identify abdominal aortic aneurysms, perforated ulcers, and other abdominal abnormalities. It will also be essential to perform an abdominal CT scan, which is a non-invasive examination that employs X-rays to make cross-sectional pictures of the components within the abdominal region. An endoscopy will be performed to evaluate the upper digestive tract, and a abdominal/chest X-ray will be taken since air beneath the diaphragm may indicate a perforated ulcer.

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 Reject/Accept the Current Diagnosis

I accept the diagnosis of acute pancreatitis; however I disagree with the diagnoses of abdominal aortic aneurysm and perforated ulcer. The symptoms of abdominal aortic aneurysm include abdominal pain, leg pain, and a pulsating belly. However, these indications are not apparent in this case, and as a result, I reject. I also reject the diagnosis of perforated ulcer since the pain linked with this condition does not spread to the back.

Three Possible Conditions

• Acute Pancreatitis:Acute pancreatitis is defined as pancreatic inflammation that occurs suddenly (Mederos et al., 2021). The most common symptom is abdominal pain. It normally subsides after a few days, although it may often become serious and life-threatening. Gallstones and excessive alcohol use are the two most prevalent causes of acute pancreatitis.
• Cholecystitis:Cholecystitis is a condition in which the gallbladder becomes inflamed. It is often caused by gallstones obstructing the tube coming from the gallbladder. This leads in an accumulation of bile, which migh
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