WEEK 7: Assignment: Assessing, Diagnosing, and Treating Abdominal, Urological, and Gynecological Disorders
\nAccurate history taking of abdominal, urological, and gynecological complaints is essential for completing an assessment of the older adult. For this Assignment, as you examine this week\u2019s patient case study, consider how you might evaluate and treat older adult patients who present with health concerns related to the abdominal, urological, or gynecological To prepare:
\nReview the case study provided by your Instructor.
\nReflect on the patient\u2019s symptoms and aspects of disorders that may be present.
\nConsider how you might assess, perform diagnostic tests, and recommend medications to treat patients presenting with the symptoms in the case.<\/p>\n
RESOURCES:
\nREQUIRED RESOURCES
\nKennedy-Malone, L., Martin-Plank, L., & Duffy, E. (2019). Urological and gynecological disorders. In Advanced practice nursing in the care of older adults (2nd ed., pp. 280\u2013304). F. A. Davis.
\nDemarest, L. (2019). Gotta go right now: What\u2019s overactive bladder? Nursing Made Incredibly Easy!, 17(4), 11\u201314. https:\/\/doi.org\/10.1097\/01.NME.0000559586.35631.37
\nJackson, P., & Vigiola, C. M. (2018). Intestinal obstruction: Evaluation and management. American Family Physician, 98(6), 362\u2013367.
\nShian, B., & Larson, S. T. (2018). Abdominal wall pain: Clinical evaluation, differential diagnosis, and treatment. American Family Physician, 98(7), 429\u2013436.
\nOTHER RESOURCES:
\nEngage-IL (Producer). (2017e). Community services for the older adult: Access and payment systems [Video]. https:\/\/engageil.com\/modules\/community-services-for-the-older-adult-access-and-payment-systems\/
\nNote: View the Community Services for the Older Adult: Access and Payment Systems video module available in this free course.
\nEngage-IL (Producer). (2017x). Providing culturally appropriate care for LGBTQ older adults [Video]. https:\/\/engageil.com\/modules\/primary-care-best-practices-for-lgbtq-older-adults\/
\nNote: View the Providing Culturally Appropriate Care for LGBTQ Older Adults video module available in this free course.
\nEngage-IL (Producer). (2017y). Sexuality and the older adult [Video]. https:\/\/engageil.com\/modules\/sexuality-and-the-older-adult\/
\nNote: View the Sexuality and the Older Adult video module available in this free course.<\/p>\n
INSTRUCTIONS::::!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
\nAccess the Focused SOAP Note Template in this week\u2019s Resources. Be sure track changes are OFF: see the instructions in doc sharing. YOU CAN ALSO USE THE SOAP WORD DOC AS YOUR TEMPLATE FOR YOUR NOTE \u2013 REMOVE ALL THE EXTRA WORDING AND INSTRUCTIONS PLEASE.
\nThe Assignment: Complete the Focused SOAP Note Template provided for the patient in the case study. Be sure to address the following:
\nSubjective: What was the patient\u2019s subjective complaint? What details did the patient provide regarding their history of present illness and personal and medical history? Include a list of prescription and over-the-counter drugs the patient is currently taking. Compare this list to the American Geriatrics Society Beers Criteria\u00ae and consider alternative drugs if appropriate. Provide a review of systems.
\nObjective: What observations did you note from the physical assessment? What were the lab, imaging, or functional assessments results?
\nAssessment: Provide a minimum of three differential diagnoses. List them from top priority to least priority. Compare the diagnostic criteria for each and explain what rules each differential in or out. Explain you critical thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case.
\nPlan: Provide a detailed treatment plan for the patient that addresses each diagnosis, as applicable. Include documentation of diagnostic studies that will be obtained, referrals to other health-care providers, therapeutic interventions, education, disposition of the patient, caregiver support, and any planned follow-up visits. Provide a discussion of health promotion and disease prevention for the patient, taking into consideration patient factors, past medical history (PMH), and other risk factors. Finally, include a reflection statement on the case that describes insights or lessons learned.
\nProvide at least three evidence-based peer-reviewed journal articles or evidenced-based guidelines, which relate to this case to support your diagnostics and differentials diagnoses. Be sure they are current (no more than 5 years old) and support the treatment plan in following current standards of care. Follow Help write my thesis – APA 7th edition formatting.
\nNOTE: SOAP notes are virtual. Please fill in any missing information. Do not write on your soap note \u201cinformation missing\u201d. You fill this information in from your past experiences with patients. Points are deducted for missing information. *remember all soap notes must contain patient health promotion and education. ALSO: if you prescribe medications, the name, route, dose, duration, and stop date is required. This is especially important in acute care.
\nMORE DETAIL ON INSTRUCTIONS
\no prepare:
\n\u2022\tReview the case study provided by your Instructor.
\n\u2022\tReflect on the patient\u2019s symptoms and aspects of disorders that may be present.
\n\u2022\tConsider how you might assess, perform diagnostic tests, and recommend medications to treat patients presenting with the symptoms in the case.
\n\u2022\tAccess the Focused SOAP Note Template in this week\u2019s Resources.
\nThe Assignment:
\nComplete the Focused SOAP Note Template provided for the patient in the case study. Be sure to address the following:
\n\u2022\tSubjective: What was the patient\u2019s subjective complaint? What details did the patient provide regarding their history of present illness and personal and medical history? Include a list of prescription and over-the-counter drugs the patient is currently taking. Compare this list to the American Geriatrics Society Beers Criteria\u00ae, and consider alternative drugs if appropriate. Provide a review of systems.
\n\u2022\tObjective: What observations did you note from the physical assessment? What were the lab, imaging, or functional assessments results?
\n\u2022\tAssessment: Provide a minimum of three differential diagnoses. List them from top priority to least priority. Compare the diagnostic criteria for each, and explain what rules each differential in or out. Explain you critical thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case.
\n\u2022\tPlan: Provide a detailed treatment plan for the patient that addresses each diagnosis, as applicable. Include documentation of diagnostic studies that will be obtained, referrals to other health-care providers, therapeutic interventions, education, disposition of the patient, caregiver support, and any planned follow-up visits. Provide a discussion of health promotion and disease prevention for the patient, taking into consideration patient factors, past medical history (PMH), and other risk factors. Finally, include a reflection statement on the case that describes insights or lessons learned.
\n\u2022\tProvide at least three evidence-based peer-reviewed journal articles or evidenced-based guidelines, which relate to this case to support your diagnostics and differentials diagnoses. Be sure they are current (no more than 5 years old) and support the treatment plan in following current standards of care. Follow Help write my thesis – APA 7th edition formatting.<\/p>\n
THE CASE SOAP NOTE:
\nWeek 7: Abdominal, Urinary, and Gynecological
\nCase 1: UTI
\nR.B. 95-year-old, white male, currently living in a skilled nursing facility (SNF)<\/p>\n
Chief complaint: \u201cMy urine is really red.\u201d<\/p>\n
HPI: On Wednesday (2 days ago) the patient was brought to your clinic by his son and complained that his urine appeared to be bright red in color. You ordered labs, urinalysis, culture, and sensitivity, and the results are below.<\/p>\n
Allergies: Penicillin: Hives<\/p>\n
Medications: Tamsulosin 0.4 mcg, 2 capsules daily, Aspirin 325 mg daily, Atorvastatin 10 mg 1 tablet daily, Donepezil 10 mg 1 tablet PO QHS, Metoprolol 25 mg 0.5 mg tablet every 12 hours, Acetaminophen 500 mg 1 tablet BID<\/p>\n
Code status: DNR Regular diet, pureed texture, honey-thickened liquids<\/p>\n
Vitals: BP 122\/70, HR 66, Temp 98.0 F, Resp 18, Pulse ox 98% Weight:____ BMI:____<\/p>\n
PMH: Cognitive communication deficit, pneumonitis due to inhalation of food and vomit, dysphagia, R-side hemiplegia and hemiparesis past ischemic CVA, moderate vascular dementia, malignant neoplasm of prostate, new-onset atrial fibrillation (12\/2019), DVT on left lower extremity, gross hematuria
\nLabs:
\nRBC 3.53 (L)
\nHemoglobin 10.2 (L)
\nMicroscopic Analysis, Urine, straight Cath
\nComponent:
\nWBC UA 42 (H) (0-5\/ HPF)
\nRBC, UA >900 (H) (0-5\/HPF)
\nEpithelial cells, urine 2 (0-4 \/HPF)
\nHyaline casts, UA 0 (0-2 \/LPF)
\nUrinalysis
\nColor Red
\nAppearance (Urine) Clear
\nKetones, UA Trace
\nSpecific gravity 1.020 (1.005-1.025)
\nBlood, UA Large
\nPH, Urine 7.0 (5.0-8.0)
\nLeukocytes Small
\nNitrites Positive<\/p>\n
C&S results were not available yet.<\/p>\n
TEMPLATE IN SEPARATE FILE:<\/p>\n
Rubric Detail<\/p>\n
Select Grid View or List View to change the rubric’s layout.
\nName: NRNP_6540_Week7_Assignment_Rubric
\n\u2022\tGrid View
\n\u2022\tList View
\nExcellent\tGood\tFair\tPoor
\nCreate documentation in the Focused SOAP Note Template about the patient in the case study to which you were assigned.<\/p>\n
In the Subjective section, provide:<\/p>\n
\u2022 Chief complaint<\/p>\n
\u2022 History of present illness (HPI)<\/p>\n
\u2022 Current medications, checked against Beers Criteria<\/p>\n
\u2022 Allergies<\/p>\n
\u2022 Patient medical history (PMHx)<\/p>\n
\u2022 Review of systems\t9 (9%) – 10 (10%)
\nThe response throughly and accurately describes the patient’s subjective complaint, history of present illness, current medications, allergies, medical history, and review of all systems that would inform a differential diagnosis. A thorough cross-check of medications against the Beers Criteria has been completed and appropriate alternative drugs recommended if applicable.\t8 (8%) – 8 (8%)
\nThe response accurately describes the patient’s subjective complaint, history of present illness, current medications, allergies, medical history, and review of all systems that would inform a differential diagnosis. A cross-check of medications against the Beers Criteria has been completed and appropriate alternative drugs recommended if applicable.\t7 (7%) – 7 (7%)
\nThe response describes the patient’s subjective complaint, history of present illness, current medications, allergies, medical history, and review of all systems that would inform a differential diagnosis, but is somewhat vague or contains minor innacuracies. A cross-check of medications against the Beers Criteria has been completed but alternatives may be missing.\t0 (0%) – 6 (6%)
\nThe response provides an incomplete or inaccurate description of the patient’s subjective complaint, history of present illness, current medications, allergies, medical history, and review of all systems that would inform a differential diagnosis. A cross-check of medications against the Beers Criteria has not been completed. Or, subjective documentation is missing.
\nIn the Objective section, provide:<\/p>\n
\u2022 Physical exam documentation of systems pertinent to the chief complaint, HPI, and history<\/p>\n
\u2022 Diagnostic results, including any labs, imaging, or other assessments needed to develop the differential diagnoses\t9 (9%) – 10 (10%)
\nThe response thoroughly and accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are thoroughly and accurately documented.\t8 (8%) – 8 (8%)
\nThe response accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are accurately documented.\t7 (7%) – 7 (7%)
\nDocumentation of the patient’s physical exam is somewhat vague or contains minor innacuracies. Diagnostic tests and their results are documented but contain minor innacuracies.\t0 (0%) – 6 (6%)
\nThe response provides incomplete or inaccurate documentation of the patient’s physical exam. Systems may have been unnecessarily reviewed, or, objective documentation is missing.
\nIn the Assessment section, provide:<\/p>\n
The response lists in order of priority at least three distinctly different and detailed possible conditions for a differential diagnosis of the patient in the assigned case study, and provides a thorough, accurate, and detailed justification for each of the conditions selected.\t20 (20%) – 22 (22%)
\nThe response lists in order of priority at least three different possible conditions for a differential diagnosis of the patient in the assigned case study and provides an accurate justification for each of the conditions selected.\t18 (18%) – 19 (19%)
\nThe response lists three possible conditions for a differential diagnosis of the patient in the assigned case study, with some vagueness and\/or inaccuracy in the conditions and\/or justification for each.\t0 (0%) – 17 (17%)
\nThe response lists two or fewer, or is missing, possible conditions for a differential diagnosis of the patient in the assigned case study, with inaccurate or missing justification for each condition selected.
\nIn the Plan section, provide:<\/p>\n
\u2022 A detailed treatment plan for the patient that addresses each diagnosis, as applicable. Includes documentation of diagnostic studies that will be obtained, referrals to other health-care providers, therapeutic interventions, education, disposition of the patient, and any planned follow up visits.<\/p>\n
\u2022 A discussion related to health promotion and disease prevention taking into consideration patient factors, PMH, and other risk factors.
\n\u2022 Reflections on the case describing insights or lessons learned.\t27 (27%) – 30 (30%)
\nThe response thoroughly and accurately outlines a treatment plan for the patient that addresses each diagnosis and includes diagnostic studies neeed, referrals, therapeutic interventions, patient education and disposition, and planned follow-up visits. A thorough and accurate discussion of health promotion and disease prevention related to the case is provided. Reflections on the case demonstrate strong critical thinking and synthesis of ideas.\t24 (24%) – 26 (26%)
\nThe response accurately outlines a treatment plan for the patient that addresses each diagnosis and includes diagnostic studies neeed, referrals, therapeutic interventions, patient education and disposition, and planned follow-up visits. An accurate discussion of health promotion and disease prevention related to the case is provided. Reflections on the case demonstrate critical thinking.\t21 (21%) – 23 (23%)
\nThe response somewhat vaguely or inaccurately outlines a treatment plan for the patient. The discussion on health promotion and disease prevention related to the case is somewhat vague or contains innaccuracies. Reflections on the case demonstrate adequate understanding of course topics.\t0 (0%) – 20 (20%)
\nThe response does not address all diagnoses or is missing elements of the treatment plan. The discussion on health promotion and disease prevention related to the case is vague, innaccurate, or missing. Reflections on the case are vague or missing.
\nProvide at least three evidence-based peer-reviewed journal articles or evidenced-based guidelines which relate to this case to support your diagnostics and differentials diagnoses. Be sure they are current (no more than 5 years old) and support the treatment plan in following current standards of care.\t9 (9%) – 10 (10%)
\nThe response provides at least three current, evidence-based resources from the literature to support the treatment plan for the patient in the assigned case study. Each resource represents the latest in standards of care and provides strong justification for treatment decisions.\t8 (8%) – 8 (8%)
\nThe response provides at least three current, evidence-based resources from the literature to support the treatment plan for the patient in the assigned case study. Each resource represents current standards of care and supports treatment decisions.\t7 (7%) – 7 (7%)
\nThree evidence-based resources are provided to support treatment decisions, but may not represent the latest in standards of care or<\/p>\n
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.\t5 (5%) – 5 (5%)
\nParagraphs and sentences follow writing standards for flow, continuity, and clarity.<\/p>\n
A clear and comprehensive purpose statement, introduction, and conclusion are provided that delineate all required criteria.\t4 (4%) – 4 (4%)
\nParagraphs and sentences follow writing standards for flow, continuity, and clarity 80% of the time.<\/p>\n
Purpose, introduction, and conclusion of the assignment are stated, yet are brief and not descriptive.\t3 (3%) – 3 (3%)
\nParagraphs and sentences follow writing standards for flow, continuity, and clarity 60%\u201379% of the time.<\/p>\n
Purpose, introduction, and conclusion of the assignment is vague or off topic.\t0 (0%) – 2 (2%)
\nParagraphs and sentences follow writing standards for flow, continuity, and clarity < 60% of the time.<\/p>\n
No purpose statement, introduction, or conclusion were provided.
\nWritten Expression and Formatting\u2014English writing standards:<\/p>\n
Correct grammar, mechanics, and proper punctuation\t5 (5%) – 5
\nContains many (\u2265 five) grammar, spelling, and punctuation errors that interfere with the reader\u2019s understanding.
\nWritten Expression and Formatting – The paper follows correct Help write my thesis – APA format for title page, headings, font, spacing, margins, indentations, page numbers, running heads, parenthetical\/in-text citations, and reference list.\t5 (5%) – 5 (5%)
\nUses correct Help write my thesis – APA format with no errors.\t4 (4%) – 4 (4%)
\nContains a few (one or two) Help write my thesis – APA format errors.\t3 (3%) – 3 (3%)
\nContains several (three or four) Help write my thesis – APA format errors.\t0 (0%) – 2 (2%)
\nContains many (\u2265 five) Help write my thesis – APA format errors.
\nTotal Points: 100
\nName: NRNP_6540_Week7_Assignment_Rubric<\/p>\n
Sample answer Focused SOAP Note<\/p>\n
Patient Information:
\nR.B. 95-year-old, white,
\nS (subjective)
\nCC (chief complaint): \u201cMy urine is really red.\u201d
\nHPI (history of present illness): R.B. 95-year-old, white male, currently living in a skilled nursing facility (SNF). On Wednesday (2 days ago) the patient was brought to your clinic by his son and complained that his urine appeared to be bright red in color. You ordered labs, urinalysis, culture, and sensitivity, and the results are below.
\nCurrent Medications: Tamsulosin 0.4 mcg, 2 capsules daily, Aspirin 325 mg daily, Atorvastatin 10 mg 1 tablet daily, Donepezil 10 mg 1 tablet PO QHS, Metoprolol 25 mg 0.5 mg tablet every 12 hours, Acetaminophen 500 mg 1 tablet BID.
\nAllergies: Penincilin and hives
\nPMHx: Cognitive communication deficit, pneumonitis due to inhalation of food and vomit, dysphagia, R-side hemiplegia and hemiparesis past ischemic CVA, moderate vascular dementia, malignant neoplasm of prostate, new-onset atrial fibrillation (12\/2019), DVT on left lower extremity, gross hematuria.
\nSoc and Substance Hx: Include occupation and major hobbies, family status, tobacco and alcohol use (previous and current use), and any other pertinent data. Always add some health promo question here, such as whether they use seat belts all the time or whether they have working smoke detectors in the house, living environment, text\/cell phone use while driving, and support system.
\nFam Hx: Married and widowed. Children and grandchildren are alive. Lives in a nursing home.
\nSurgical Hx: Splenectomy at 55 years.
\nMental Hx: History of depression and suicidal ideation. Treated with no reoccurrence.
\nViolence Hx: No history of violence self-harm.
\nReproductive Hx: Not sexually active. Has three daughters.
\nROS (review of symptoms):
\nGENERAL: No unintentional weight changes or fever.
\nHEENT:
\n\u2022\tEyes: No visual loss or watery eyes.
\n\u2022\tEars, Nose, Throat: No hearing loss, congestion of the nose, or sore throat.
\nSKIN: No rashes.
\nCARDIOVASCULAR: No palpitation or edema.
\nRESPIRATORY: No shortness of breath.
\nGASTROINTESTINAL: No nausea or vomiting.
\nGENITOURINARY: Urine is red.
\nNEUROLOGICAL: No headache or changes in bladder control.
\nMUSCULOSKELETAL: No back pain or muscle stiffness.
\nHEMATOLOGIC: No bleeding.
\nLYMPHATICS: History of splenectomy.
\nPSYCHIATRIC: History of depression or anxiety.
\nENDOCRINOLOGIC: No sweating.
\nREPRODUCTIVE: Not sexually active.
\nALLERGIES: Penicillin and hives.
\nO (objective)
\nPhysical exam:
\nVital signs: BP 122\/70, HR 66, Temp 98.0 F, Resp 18, Pulse ox 98.
\nDiagnostic results:
\nLabs:
\nRBC 3.53 (L)
\nHemoglobin 10.2 (L)
\nMicroscopic Analysis, Urine, straight Cath
\nComponent:
\nWBC UA 42 (H) (0-5\/ HPF)
\nRBC, UA >900 (H) (0-5\/HPF)
\nEpithelial cells, urine 2 (0-4 \/HPF)
\nHyaline casts, UA 0 (0-2 \/LPF)
\nUrinalysis
\nColor Red
\nAppearance (Urine): Clear
\nKetones, UA Trace
\nSpecific gravity 1.020 (1.005-1.025)
\nBlood, UA Large
\nPH, Urine 7.0 (5.0-8.0)
\nLeukocytes Small
\nNitrites Positive<\/p>\n
A (assessment)
\nDifferential diagnoses:
\nCancerous and noncancerous tumors
\nA tumor in the urinary system can cause a change in the color of the urine. Elderly people above 50 years have a tumor or changes in urine color due to an enlarged prostate gland (McIntire et al., 2020).
\nUrinary tract infection (UTI)
\nUTI is an infection of the urinary system causing red color on the urine. Symptoms of UTI include intense urge to pee, dark or red color of the urine, fever, or chills. Patients with UTI require urgent care (Cavanaugh & Perazella, 2019).
\nKidney cysts
\nKidney cysts may cause no adverse symptoms but patients can experience red urine if the cysts burst. Patients with kidney cysts are likely to experience intense and frequent urges to urinate (Alaygut et al., 2021).
\nP (plan)
\nThe patient should be referred for an X-ray and additional examination of the urine to determine the appropriate diagnosis. The patient should start taking medication and report to the clinic after two weeks.
\nI learned that elderly men are at risk of the enlarged prostate gland which increases the risk of red and dark urine. It is essential to diagnose the patient to ensure appropriate treatment.
\nThe patient should drink sufficient water daily and avoid hard tasks that may cause sweating. It is important to eat a healthy diet to boost immunity. The practitioner should maintain confidentiality in the delivery of care.<\/p>\n
References
\nAlaygut, D., Erfidan, G., Soyalt\u0131n, E., Sivi\u015f, Z. \u00d6., \u00c7amlar, S. A., Mutluba\u015f, F., & Demir, B. K. (2021). What does acute kidney injury and dark red-brown urine that appear after bone marrow transplantation tell us: Questions. Pediatric Nephrology, 36(1), 65-66.
\nCavanaugh, C., & Perazella, M. A. (2019). Urine sediment examination in the diagnosis and management of kidney disease: core curriculum 2019. American Journal of Kidney Diseases, 73(2), 258-272.
\nMcIntire, P. J., Kilic, I., Wojcik, E. M., Barkan, G. A., & Pambuccian, S. E. (2020). The color of urine: then and now\u2014a comprehensive review of the literature with emphasis on intracytoplasmic pigments encountered in urinary cytology. Journal of the American Society of Cytopathology, 9(1), 9-19.<\/p>\n","protected":false},"excerpt":{"rendered":"
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