WEEK 10 LAB ASSIGNMENT: ASSESSING THE GENITALIA AND RECTUM WALDEN UNIVERSITY

WEEK 10 LAB ASSIGNMENT: ASSESSING THE GENITALIA AND RECTUM WALDEN UNIVERSITY

WEEK 10 LAB ASSIGNMENT: ASSESSING THE GENITALIA AND RECTUM WALDEN UNIVERSITY

Analyze SOAP note and document missing information:

Genitourinary Assessment

CC: Increased frequency and pain with urination

HPI:

T.S. is a 32-year-old woman who reports that for the past two days, she has dysuria, frequency, and urgency. Has not tried anything to help with the discomfort. Has had this symptom years ago. She is sexually active and has a new partner for the past 3 months.

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Medical History:

None

Surgical History:

• Tonsillectomy in 2001
• Appendectomy in 2020

Review of Systems:

• General: Denies weight change, positive for sleeping difficulty because e the flank pain. Feels warm.
• Abdominal: Denies nausea and vomiting. No appetite

Objective 

VSS T = 37.3°C, P = 102/min, RR = 16/min, and BP = 116/74 mm Hg.

Pelvic Exam:

• mild tenderness to palpation in the suprapubic area
• bimanual pelvic examination reveals a normal-sized uterus and adnexae
• no adnexal tenderness.
• No vaginal discharge is noted.
• The cervix appears normal.
• Diagnostics: Urinalysis, STI testing, Papsmear

Assessment:

• UTI
• STI

PLAN: This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.

Patients are frequently uncomfortable discussing with healthcare 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 Lab Assignment, you will analyze an Episodic 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.

RESOURCES

Be sure to review the Learning Resources before completing this activity.

Click the weekly resources link to access the resources.

WEEKLY RESOURCES

LEARNING RESOURCES

Required Readings

• 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.
• Chapter 17, “Breasts and Axillae”
• This chapter focuses on examining the breasts and axillae. The authors describe the examination procedures and the anatomy and physiology of breasts.
• Chapter 19, “Female Genitalia”
• In this chapter, the authors explain how to conduct an examination of female genitalia. The chapter also describes the form and function of female genitalia.
• Chapter 20, “Male Genitalia”
• The authors explain the biology of the penis, testicles, epididymides, scrotum, prostate gland, and seminal vesicles. Additionally, the chapter explains how to perform an exam of these areas.
• Chapter 21, “Anus, Rectum, and Prostate”
• This chapter focuses on performing an exam of the anus, rectum, and prostate. The authors also explain the anatomy and physiology of the anus, rectum, and prostate.
• 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 5, “Amenorrhea”
• Download Chapter 5, “Amenorrhea”
• Amenorrhea, or the absence of menstruation, is the focus of this chapter. The authors include key questions to ask patients when taking histories and explain what to look for in the physical exam.
• Chapter 6, “Breast Lumps and Nipple Discharge”
• Download Chapter 6, “Breast Lumps and Nipple Discharge”
• This chapter focuses on the important topic of breast lumps and nipple discharge. Because breast cancer is the most common type of cancer in women, it is important to get an accurate diagnosis. Information in the chapter includes key questions to ask and what to look for in the physical exam.
• Chapter 7, “Breast Pain”
• Download Chapter 7, “Breast Pain”
• Determining the cause of breast pain can be difficult. This chapter examines how to determine the likely cause of the pain through diagnostic tests, physical examination, and careful analysis of a patient’s health history.
• Chapter 27, “Penile Discharge”
• Download Chapter 27, “Penile Discharge”
• The focus of this chapter is on how to diagnose the causes of penile discharge. The authors include specific questions to ask when gathering a patient’s history to narrow down the likely diagnosis. They also give advice on performing a focused physical exam.
• Chapter 36, “Vaginal Bleeding”
• Download Chapter 36, “Vaginal Bleeding”
• In this chapter, the causes of vaginal bleeding are explored. The authors focus on symptoms outside the regular menstrual cycle. The authors discuss key questions to ask the patient as well as specific physical examination procedures and laboratory studies that may be useful in reaching a diagnosis.
• Chapter 37, “Vaginal Discharge and Itching”
• Download Chapter 37, “Vaginal Discharge and Itching”
• This chapter examines the process of identifying causes of vaginal discharge and itching. The authors include questions on the characteristics of the discharge, the possibility of the issues being the result of a sexually transmitted infection, and how often the discharge occurs. A chart highlights potential diagnoses based on patient history, physical findings, and diagnostic studies.
• Sullivan, D. D. (2019). Guide to clinical documentation (3rd ed.). Philadelphia, PA: F. A. Davis.
• Chapter 3, “SOAP Notes” (Previously read in Week 8)
• Centers for Disease Control and Prevention. (2021, April 13). Sexually transmitted disease surveillance, 2019
•  
• Links to an external site.
• .
•  
• Links to an external site.
• https://www.cdc.gov/std/#
• This section of the CDC website provides a range of information on sexually transmitted diseases (STDs). The website includes reports on STDs, related projects and initiatives, treatment information, and program tools.
• Document: Final Exam Review (Word document)
• Download Final Exam Review (Word document)

Required Media

It is highly recommended that you access and view the resources included with the course text, Seidel’s Guide to Physical Examination. Focus on the videos and animations in Chapters 16 and 18–20 that relate to special examinations, including breast, genital, prostate, and rectal. Refer to the Week 4 Learning Resources area for access instructions on https://evolve.elsevier.com/

Links to an external site.

Optional Resources

• LeBlond, R. F., Brown, D. D., & DeGowin, R. L. (2020). DeGowin’s diagnostic examination (11th ed.). New York, NY: McGraw Hill Medical.
• Chapter 8, “The Chest: Chest Wall, Pulmonary, and Cardiovascular Systems; The Breasts” (Section 2, “The Breasts,” pp. 380-390)
• Section 2 of this chapter focuses on the anatomy and physiology of breasts. The section provides descriptions of breast examinations and common breast conditions.
• Chapter 11, “The Female Genitalia and Reproductive System”
• In this chapter, the authors provide an overview of the female reproductive system. The authors also describe symptoms of disorders in the reproductive system.
• Chapter 12, “The Male Genitalia and Reproductive System”
• The authors of this chapter detail the anatomy of the male reproductive system. Additionally, the authors describe how to conduct an exam of the male reproductive system.
• Review of Chapter 9, “The Abdomen, Perineum, Anus, and Rectosigmoid”
• Mealey, K., Braverman, P. K., & Koenigs, L. M. (2019). Why a pelvic exam is needed to diagnose cervicitis and pelvic inflammatory disease.
•  
• Links to an external site.
• Annals of Emergency Medicine, 73(4), 424–425. https://doi.org/10.1016/j.annemergmed.2018.11.028
• Sanchez, C., Israel, R., Hughes, C., & Gorman, N. (2019). Well-woman examinations: Beyond cervical cancer screening.
•  
• Links to an external site.
• The Journal for Nurse Practitioners, 15(2), 189–194.e2. https://doi.org/10.1016/j.nurpra.2018.09.005

TO PREPARE

• 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.
• Based on the Episodic note case study:
• Review this week’s Learning Resources, and consider the insights they provide about the case study. Refer to Chapter 3 of the Sullivan resource to guide you as you complete your Lab Assignment.
• Search the Walden library or the Internet for evidence-based resources to support your answers to the questions provided.
• 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.

THE LAB ASSIGNMENT

Using evidence-based resources from your search, 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 three different references from current evidence-based literature.

BY DAY 7 OF WEEK 10

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Rubric

NURS_6512_Week_10_Assignment1_Rubric

CriteriaRatingsPtsThis criterion is linked to a Learning Outcome

With regard to the SOAP note case study provided and using evidence-based resources from your search, 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.12 to >9.0 pts

Excellent

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.

9 to >6.0 pts

Good

The response accurately analyzes the subjective portion of the SOAP note and lists additional information to be included in the documentation.

6 to >3.0 pts

Fair

The response vaguely analyzes the subjective portion of the SOAP note and vaguely and/or inaccurately lists additional information to be included in the documentation.

3 to >0 pts

Poor

The response inaccurately analyzes the subjective portion of the SOAP note, with inaccurate and/or missing additional information included in the documentation.

12 pts

This criterion is linked to a Learning Outcome

·  Analyze the objective portion of the note. List additional information that should be included in the documentation.12 to >9.0 pts

Excellent

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.

9 to >6.0 pts

Good

The response accurately analyzes the objective portion of the SOAP note and lists additional information to be included in the documentation.

6 to >3.0 pts

Fair

The response vaguely analyzes the objective portion of the SOAP note and vaguely and/or inaccurately lists additional information to be included in the documentation.

3 to >0 pts

Poor

The response inaccurately analyzes the objective portion of the SOAP note, with inaccurate and/or missing additional information included in the documentation.

12 pts

This criterion is linked to a Learning Outcome

·  Is the assessment supported by the subjective and objective information? Why or why not?16 to >13.0 pts

Excellent

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.

13 to >10.0 pts

Good

The response accurately identifies whether or not the assessment is supported by the subjective and/or objective information, with a clear explanation.

10 to >7.0 pts

Fair

The response vaguely identifies whether or not the assessment is supported by the subjective and/or objective information, with a vague explanation.

7 to >0 pts

Poor

The response inaccurately identifies whether or not the assessment is supported by the subjective and/or objective information, with an inaccurate or missing explanation.

16 pts

This criterion is linked to a Learning Outcome

·  What diagnostic tests would be appropriate for this case, and how would the results be used to make a diagnosis?20 to >17.0 pts

Excellent

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.

17 to >14.0 pts

Good

The response accurately describes appropriate diagnostic tests for the case and explains how the test results would be used to make a diagnosis.

14 to >11.0 pts

Fair

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.

11 to >0 pts

Poor

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.

20 pts

This criterion is linked to a Learning Outcome

·  Would you reject or accept the current diagnosis? Why or why not?·  Identify three possible conditions that may be considered as a differenial diagnosis for this patient. Explain your reasoning using at least three different references from current evidence-based literature.25 to >22.0 pts

Excellent

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 three or more different references from current evidence-based literature.

22 to >19.0 pts

Good

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 using three different references from current evidence-based literature.

19 to >16.0 pts

Fair

The response states whether to accept or reject the current diagnosis, with a vague explanation of the reasoning. The response identifies two to three conditions as a differential diagnosis, with reasoning that is explained vaguely and/or inaccurately using three or fewer references from current evidence-based literature.

16 to >0 pts

Poor

The response inaccurately states 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 three or fewer conditions as a differential diagnosis, with reasoning that is missing or explained inaccurately using two or fewer references from current evidence-based literature.

25 pts

This criterion is linked to a Learning Outcome

Written Expression and Formatting – Paragraph Development and Organization: Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused–neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria.5 to >4.0 pts

Excellent

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.

4 to >3.0 pts

Good

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.

3 to >2.0 pts

Fair

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.

2 to >0 pts

Poor

Paragraphs and sentences follow writing standards for flow, continuity, and clarity < 60% of the time. No purpose statement, introduction, or conclusion were provided.

5 pts

This criterion is linked to a Learning Outcome

Written Expression and Formatting – English writing standards: Correct grammar, mechanics, and proper punctuation5 to >4.0 pts

Excellent

Uses correct grammar, spelling, and punctuation with no errors.

4 to >3.0 pts

Good

Contains a few (1 or 2) grammar, spelling, and punctuation errors.

3 to >2.0 pts

Fair

Contains several (3 or 4) grammar, spelling, and punctuation errors.

2 to >0 pts

Poor

Contains many (≥ 5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding.

5 pts

This criterion is linked to a Learning Outcome

Written Expression and Formatting – The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, running heads, parenthetical/in-text citations, and reference list.5 to >4.0 pts

Excellent

Uses correct APA format with no errors.

4 to >3.0 pts

Good

Contains a few (1 or 2) APA format errors.

3 to >2.0 pts

Fair

Contains several (3 or 4) APA format errors.

2 to >0 pts

Poor

Contains many (≥ 5) APA format errors.

5 pts

Total Points: 100

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