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NURS6512 Week 6 Discussion: Assessing the Heart, Lungs, and Peripheral Vascular System
NURS6512 Week 6 Discussion: Assessing the Heart, Lungs, and Peripheral Vascular System
Take a moment to observe your breathing. Notice the sensation of your chest expanding as air flows into your lungs. Feel your chest contract as you exhale. How might this experience be different for someone with chronic lung disease or someone experiencing an asthma attack?
In order to adequately assess the chest region of a patient, nurses need to be aware of a patient’s history, potential abnormal findings, and what physical exams and diagnostic tests should be conducted to determine the causes and severity of abnormalities.
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In this Discussion, you will consider how a patient’s initial symptoms can result in very different diagnoses when further assessment is conducted.
Note: By Day 1 of this week, your Instructor will have assigned you to one of the video case studies in this week’s Learning Resources titled Advanced health assessment and diagnostic reasoning. Also, your Discussion post should be in the SOAP Note format, rather than the traditional narrative style Discussion posting format. Refer to Chapter 2 of the Sullivan text and the Comprehensive SOAP Template in the Week 4 Learning Resources for guidance. Remember that not all comprehensive SOAP data are included in every patient case.
To prepare for NURS6512 Week 6 Discussion: Assessing the Heart, Lungs, and Peripheral Vascular System:
With regard to the case study you were assigned:
Review this week’s Learning Resources and consider the insights they provide.
Consider what history would be necessary to collect from the patient.
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.
Note: Before you submit your initial post, replace the subject line (“Discussion – Week 6”) with “Review of Case Study” identifying the number of the case study you were assigned.
By Day 3 of NURS6512 Week 6 Discussion: Assessing the Heart, Lungs, and Peripheral Vascular System
Post a description of the health history you would need to collect from the patient in the case study you were assigned. Explain what physical exams and diagnostic tests would be appropriate and how the results would be used to make a diagnosis. List five different possible conditions for the patient’s differential diagnosis, and justify why you selected each.
Read a selection of your colleagues’ responses.
By Day 6 of NURS6512 Week 6 Discussion: Assessing the Heart, Lungs, and Peripheral Vascular System
Respond to at least two of your colleagues on two different days who were assigned different case studies than you. Analyze the possible conditions from your colleagues’ differential diagnoses. Determine which of the conditions you would reject and why. Identify the most likely condition, and justify your reasoning.
NURS 6512 Week 6 Assignment: 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.”
HPI: 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.
PMH: HTN, Diabetes, hx of GI bleed 4 years ago
Medications: Lisinopril 10mg, Amlodipine 5 mg, Metformin 1000mg, Lantus 10 units qhs
Allergies: NKDA
FH: No hx of colon cancer, Father hx DMT2, HTN, Mother hx HTN, Hyperlipidemia, GERD
Social: Denies tobacco use; occasional etoh, 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: RRR, no murmurs
Lungs: CTA, chest wall symmetrical
Skin: Intact without lesions, no urticaria
Abd: soft, hyperctive bowel sounds, pos pain in the LLQ
Diagnostics: None
ASSESSMENT:
Left lower quadrant pain
Gastroenteritis
PLAN: This section is not required for the assignments in this course (NURS 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.
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NURS 6512 Week 10 Assignment 1: Assessing the Genitalia and Rectum
Patients are frequently uncomfortable discussing with health care professional’s issues that involve the genitalia and rectum; however, gathering an adequate history and properly conducting a physical exam are vital. Examining case studies of genital and rectal abnormalities can help prepare advanced practice nurses to accurately assess patients with problems in these areas.
In this assignment, you will consider case studies that describe abnormal findings in patients seen in a clinical setting.
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.
GENITALIA ASSESSMENT
Subjective:
- CC: “I have bumps on my bottom that I want to have checked out.”
- HPI: AB, a 21-year-old WF college student reports to your clinic with external bumps on her genital area. She states the bumps are painless and feel rough. She states she is sexually active and has had more than one partner over the past year. Her initial sexual contact occurred at age 18. She reports no abnormal vaginal discharge. She is unsure how long the bumps have been there but noticed them about a week ago. Her last Pap smear exam was 3 years ago, and no dysplasia was found; the exam results were normal. She reports one sexually transmitted infection (chlamydia) about 2 years ago. She completed the treatment for chlamydia as prescribed.
- PMH: Asthma
- Medications: Symbicort 160/4.5mcg
- Allergies: NKDA
- FH: No hx of breast or cervical cancer, Father hx HTN, Mother hx HTN, GERD
- Social: Denies tobacco use; occasional etoh, married, 3 children (1 girl, 2 boys)
Objective:
- VS: Temp 98.6; BP 120/86; RR 16; P 92; HT 5’10”; WT 169lbs
- Heart: RRR, no murmurs
- Lungs: CTA, chest wall symmetrical
- Genital: Normal female hair pattern distribution; no masses or swelling. Urethral meatus intact without erythema or discharge. Perineum intact with a healed episiotomy scar present. Vaginal mucosa pink and moist with rugae present, pos for firm, round, small, painless ulcer noted on external labia
- Abd: soft, normoactive bowel sounds, neg rebound, neg murphy’s, neg McBurney
- Diagnostics: HSV specimen obtained
Assessment:
- Chancre
- PLAN: This section is not required for the assignments in this course (NURS 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:
Refer to Chapter 5 of the Sullivan text. Analyze the SOAP note case study. Using evidence based resources, answer the following questions and support your answers using current evidence from the literature.
- 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?
- Would diagnostics 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.