What diagnostic tests would be appropriate for this case, and how would the results be used to make a diagnosis?

Assessment of the Abdomen and Gastrointestinal System

Abdominal Assessment Case Study SOAP Note

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, hyperactive 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.

The Assignment Instructions

Do this assignment in narrative form and not SOAP note form. Please follow the rubric.

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.

What diagnostic tests would be appropriate for this case, and how would the results be used to make a diagnosis?

Assessment of the Abdomen and Gastrointestinal System

Abdominal Assessment Case Study SOAP Note

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, hyperactive 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.

The Assignment Instructions

Do this assignment in narrative form and not SOAP note form. Please follow the rubric.

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.

Describe any potential challenges or risks that may be inherent in the technologies associated with these trends you described.

Healthcare Information Technology Trends
Throughout history, technological advancements have appeared for one purpose before finding applications elsewhere that lead to spikes in its usage and development. The internet, for example, was originally developed to share research before becoming a staple of work and entertainment. But technology—new and repurposed—will undoubtedly continue to be a driver of healthcare information. Informaticists often stay tuned to trends to monitor what the next new technology will be or how the next new idea for applying existing technology can benefit outcomes.

In this Discussion, you will reflect on your healthcare organization’s use of technology and offer a technology trend you observe in your environment.

To Prepare:

Reflect on the Resources related to digital information tools and technologies.
Consider your healthcare organization’s use of healthcare technologies to manage and distribute information.
Reflect on current and potential future trends, such as use of social media and mobile applications/telehealth, Internet of Things (IoT)-enabled asset tracking, or expert systems/artificial intelligence, and how they may impact nursing practice and healthcare delivery.
By Day 3 of Week 6
Post a brief description of general healthcare technology trends, particularly related to data/information you have observed in use in your healthcare organization or nursing practice. Describe any potential challenges or risks that may be inherent in the technologies associated with these trends you described. Then, describe at least one potential benefit and one potential risk associated with data safety, legislation, and patient care for the technologies you described. Next, explain which healthcare technology trends you believe are most promising for impacting healthcare technology in nursing practice and explain why. Describe whether this promise will contribute to improvements in patient care outcomes, efficiencies, or data management. Be specific and provide examples.

Required Readings
McGonigle, D., & Mastrian, K. G. (2017). Nursing informatics and the foundation of knowledge (4th ed.). Burlington, MA: Jones & Bartlett Learning.

Chapter 14, “The Electronic Health Record and Clinical Informatics” (pp. 267–287)
Chapter 15, “Informatics Tools to Promote Patient Safety and Quality Outcomes” (pp. 293–317)
Chapter 16, “Patient Engagement and Connected Health” (pp. 323–338)
Chapter 17, “Using Informatics to Promote Community/Population Health” (pp. 341–355)
Chapter 18, “Telenursing and Remote Access Telehealth” (pp. 359–388)
Dykes, P. C., Rozenblum, R., Dalal, A., Massaro, A., Chang, F., Clements, M., Collins, S. …Bates, D. W. (2017). Prospective evaluation of a multifaceted intervention to improve outcomes in intensive care: The Promoting Respect and Ongoing Safety Through Patient Engagement Communication and Technology Study. Critical Care Medicine, 45(8), e806–e813. doi:10.1097/CCM.0000000000002449

HealthIT.gov. (2018c). What is an electronic health record (EHR)? Retrieved from https://www.healthit.gov/faq/what-electronic-health-record-ehr

Rao-Gupta, S., Kruger, D. Leak, L. D., Tieman, L. A., & Manworren, R. C. B. (2018). Leveraging interactive patient care technology to Improve pain management engagement. Pain Management Nursing, 19(3), 212–221. doi:10.1016/j.pmn.2017.11.002

Skiba, D. (2017). Evaluation tools to appraise social media and mobile applications. Informatics, 4(3), 32–40. doi:10.3390/informatics4030032

Required Media
Laureate Education (Producer). (2018). Public Health Informatics [Video file]. Baltimore, MD: Author.

Accessible player
Laureate Education (Producer). (2018). Electronic Records and Managing IT Change [Video file]. Baltimore, MD: Author.

Describe any potential challenges or risks that may be inherent in the technologies associated with these trends you described.

Healthcare Information Technology Trends
Throughout history, technological advancements have appeared for one purpose before finding applications elsewhere that lead to spikes in its usage and development. The internet, for example, was originally developed to share research before becoming a staple of work and entertainment. But technology—new and repurposed—will undoubtedly continue to be a driver of healthcare information. Informaticists often stay tuned to trends to monitor what the next new technology will be or how the next new idea for applying existing technology can benefit outcomes.

In this Discussion, you will reflect on your healthcare organization’s use of technology and offer a technology trend you observe in your environment.

To Prepare:

Reflect on the Resources related to digital information tools and technologies.
Consider your healthcare organization’s use of healthcare technologies to manage and distribute information.
Reflect on current and potential future trends, such as use of social media and mobile applications/telehealth, Internet of Things (IoT)-enabled asset tracking, or expert systems/artificial intelligence, and how they may impact nursing practice and healthcare delivery.
By Day 3 of Week 6
Post a brief description of general healthcare technology trends, particularly related to data/information you have observed in use in your healthcare organization or nursing practice. Describe any potential challenges or risks that may be inherent in the technologies associated with these trends you described. Then, describe at least one potential benefit and one potential risk associated with data safety, legislation, and patient care for the technologies you described. Next, explain which healthcare technology trends you believe are most promising for impacting healthcare technology in nursing practice and explain why. Describe whether this promise will contribute to improvements in patient care outcomes, efficiencies, or data management. Be specific and provide examples.

Required Readings
McGonigle, D., & Mastrian, K. G. (2017). Nursing informatics and the foundation of knowledge (4th ed.). Burlington, MA: Jones & Bartlett Learning.

Chapter 14, “The Electronic Health Record and Clinical Informatics” (pp. 267–287)
Chapter 15, “Informatics Tools to Promote Patient Safety and Quality Outcomes” (pp. 293–317)
Chapter 16, “Patient Engagement and Connected Health” (pp. 323–338)
Chapter 17, “Using Informatics to Promote Community/Population Health” (pp. 341–355)
Chapter 18, “Telenursing and Remote Access Telehealth” (pp. 359–388)
Dykes, P. C., Rozenblum, R., Dalal, A., Massaro, A., Chang, F., Clements, M., Collins, S. …Bates, D. W. (2017). Prospective evaluation of a multifaceted intervention to improve outcomes in intensive care: The Promoting Respect and Ongoing Safety Through Patient Engagement Communication and Technology Study. Critical Care Medicine, 45(8), e806–e813. doi:10.1097/CCM.0000000000002449

HealthIT.gov. (2018c). What is an electronic health record (EHR)? Retrieved from https://www.healthit.gov/faq/what-electronic-health-record-ehr

Rao-Gupta, S., Kruger, D. Leak, L. D., Tieman, L. A., & Manworren, R. C. B. (2018). Leveraging interactive patient care technology to Improve pain management engagement. Pain Management Nursing, 19(3), 212–221. doi:10.1016/j.pmn.2017.11.002

Skiba, D. (2017). Evaluation tools to appraise social media and mobile applications. Informatics, 4(3), 32–40. doi:10.3390/informatics4030032

Required Media
Laureate Education (Producer). (2018). Public Health Informatics [Video file]. Baltimore, MD: Author.

Accessible player
Laureate Education (Producer). (2018). Electronic Records and Managing IT Change [Video file]. Baltimore, MD: Author.