Assignment 4 Abdominal Discomfort Assessment Esther Park

Assignment 4 Abdominal Discomfort Assessment Esther Park

Assignment 4 Abdominal Discomfort Assessment Esther Park: 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 Esther Park 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.

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• 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)

Assignment 4 Abdominal Discomfort Assessment Esther Park Competency

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.
• 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.
• 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. Assignment 4: Abdominal Discomfort Assessment Esther Park

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.

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.

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.

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.

COMMENTS:

TOTAL:  /100

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

Your Results

Reopen (/assignment_attempts/6077725/reopen

Lab Pass (/assignment attempts/6077725/lab_pass.p

Overview Transcript

Objective Data Collection: 21 of 21 (100%)

Subjective Data Collection

Objective Data Collection

• Correct
• Partially correct
• Incorrect
• Missed

Education & Empathy Documentation

• Inspected head and face 1 of 1 point

Care Plan

Skull Symmetry (1/3 point)

• Symmetric
• Asymmetric

Facial Feature Symmetry (1/3 point)

• Symmetric
• Asymmetric

Appearance (1/3 point)

• Not 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)

• 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