05 Oct Review the Episodic note case study your instructo
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.The Assignment Posted on: Sunday, September 29, 2019 6:12:00 PM EDTStudents will:Evaluate abnormal abdomen and gastrointestinal findings Apply concepts, theories, and principles relating to health assessment techniques and diagnoses for the abdomen and gastrointestinal system Identify concepts, theories, and principles related to advanced health assessment CASE STUDY IS LOCATED IN THE DOC SHARING TAB 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. CASE STUDYWeek 6: Assessment of the Abdomen and Gastrointestinal System ABDOMINAL ASSESSMENT Subjective: 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.units qhsHyperlipidemia, GERDObjective: Assessment: PLAN: This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.© 2019 Walden University. All Rights Reserved Select Grid View or List View to change the rubric’s layout.Show DescriptionsExcellent 10 (10%) – 12 (12%)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.Good 7 (7%) – 9 (9%)The response accurately analyzes the subjective portion of the SOAP note and lists additional information to be included in the documentation.Fair 4 (4%) – 6 (6%)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.Poor 0 (0%) – 3 (3%)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.Excellent 10 (10%) – 12 (12%)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.Good 7 (7%) – 9 (9%)The response accurately analyzes the objective portion of the SOAP note and lists additional information to be included in the documentation.Fair 4 (4%) – 6 (6%)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.Poor 0 (0%) – 3 (3%)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.Excellent 14 (14%) – 16 (16%)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.Good 11 (11%) – 13 (13%)The response accurately identifies whether or not the assessment is supported by the subjective and/or objective information, with an explanation.Fair 8 (8%) – 10 (10%)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.Poor 0 (0%) – 7 (7%)The response inaccurately identifies whether or not the assessment is supported by the subjective and/or objective information, with an inaccurate or missing explanation.Excellent 18 (18%) – 20 (20%)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.Good 15 (15%) – 17 (17%)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.Fair 12 (12%) – 14 (14%)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.Poor 0 (0%) – 11 (11%)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.Excellent 23 (23%) – 25 (25%)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.Good 20 (20%) – 22 (22%)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.Fair 17 (17%) – 19 (19%)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.Poor 0 (0%) – 16 (16%)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.Excellent 5 (5%) – 5 (5%)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.Good 4 (4%) – 4 (4%)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.Fair 3 (3%) – 3 (3%)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.Poor 0 (0%) – 2 (2%)Paragraphs and sentences follow writing standards for flow, continuity, and clarity < 60% of the time. No purpose statement, introduction, or conclusion were provided.Excellent 5 (5%) – 5 (5%)Uses correct grammar, spelling, and punctuation with no errors.Good 4 (4%) – 4 (4%)Contains a few (1 or 2) grammar, spelling, and punctuation errors.Fair 3 (3%) – 3 (3%)Contains several (3 or 4) grammar, spelling, and punctuation errors.Poor 0 (0%) – 2 (2%)Contains many (≥ 5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding.Excellent 5 (5%) – 5 (5%)Uses correct APA format with no errors.Good 4 (4%) – 4 (4%)Contains a few (1 or 2) APA format errors.Fair 3 (3%) – 3 (3%)Contains several (3 or 4) APA format errors.Poor 0 (0%) – 2 (2%)Contains many (≥ 5) APA format errors. Required Readings (click to expand/reduce) Note: To access this week’s required library resources, please click on the link to the Course Readings List, found in the Course Materials section of your Syllabus.Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby. 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” 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” 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” 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” 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.
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