WEEK 7: Assignment: Assessing, Diagnosing, and Treating Abdominal, Urological, and Gynecological Disorders
Accurate 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’s 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:
Review the case study provided by your Instructor.
Reflect on the patient’s symptoms and aspects of disorders that may be present.
Consider how you might assess, perform diagnostic tests, and recommend medications to treat patients presenting with the symptoms in the case.
RESOURCES:
REQUIRED RESOURCES
Kennedy-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. 280–304). F. A. Davis.
Demarest, L. (2019). Gotta go right now: What’s overactive bladder? Nursing Made Incredibly Easy!, 17(4), 11–14. https://doi.org/10.1097/01.NME.0000559586.35631.37
Jackson, P., & Vigiola, C. M. (2018). Intestinal obstruction: Assessment and management. American Family Physician, 98(6), 362–367.
Shian, B., & Larson, S. T. (2018). Abdominal wall pain: Clinical Assessment, differential diagnosis, and treatment. American Family Physician, 98(7), 429–436.
OTHER RESOURCES:
Engage-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/
Note: View the Community Services for the Older Adult: Access and Payment Systems video module available in this free course.
Engage-IL (Producer). (2017x). Providing culturally appropriate care for LGBTQ older adults [Video]. https://engageil.com/modules/primary-care-best-practices-for-lgbtq-older-adults/
Note: View the Providing Culturally Appropriate Care for LGBTQ Older Adults video module available in this free course.
Engage-IL (Producer). (2017y). Sexuality and the older adult [Video]. https://engageil.com/modules/sexuality-and-the-older-adult/
Note: View the Sexuality and the Older Adult video module available in this free course.
INSTRUCTIONS::::!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
Access the Focused SOAP Note Template in this week’s 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 – REMOVE ALL THE EXTRA WORDING AND INSTRUCTIONS PLEASE.
The Assignment: Complete the Focused SOAP Note Template provided for the patient in the case study. Be sure to address the following:
Subjective: What was the patient’s 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® and consider alternative drugs if appropriate. Provide a review of systems.
Objective: What observations did you note from the physical assessment? What were the lab, imaging, or functional assessments results?
Assessment: 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.
Plan: 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.
Provide 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 APA 7th edition formatting.
NOTE: SOAP notes are virtual. Please fill in any missing information. Do not write on your soap note “information missing”. 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.
MORE DETAIL ON INSTRUCTIONS
o prepare:
• Review the case study provided by your Instructor.
• Reflect on the patient’s symptoms and aspects of disorders that may be present.
• Consider how you might assess, perform diagnostic tests, and recommend medications to treat patients presenting with the symptoms in the case.
• Access the Focused SOAP Note Template in this week’s Resources.
The Assignment:
Complete the Focused SOAP Note Template provided for the patient in the case study. Be sure to address the following:
• Subjective: What was the patient’s 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®, and consider alternative drugs if appropriate. Provide a review of systems.
• Objective: What observations did you note from the physical assessment? What were the lab, imaging, or functional assessments results?
• Assessment: 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.
• Plan: 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.
• Provide 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 APA 7th edition formatting.
THE CASE SOAP NOTE:
Week 7: Abdominal, Urinary, and Gynecological
Case 1: UTI
R.B. 95-year-old, white male, currently living in a skilled nursing facility (SNF)
Chief complaint: “My urine is really red.”
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.
Allergies: Penicillin: Hives
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
Code status: DNR Regular diet, pureed texture, honey-thickened liquids
Vitals: BP 122/70, HR 66, Temp 98.0 F, Resp 18, Pulse ox 98% Weight:____ BMI:____
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
Labs:
RBC 3.53 (L)
Hemoglobin 10.2 (L)
Microscopic Analysis, Urine, straight Cath
Component:
WBC UA 42 (H) (0-5/ HPF)
RBC, UA >900 (H) (0-5/HPF)
Epithelial cells, urine 2 (0-4 /HPF)
Hyaline casts, UA 0 (0-2 /LPF)
Urinalysis
Color Red
Appearance (Urine) Clear
Ketones, UA Trace
Specific gravity 1.020 (1.005-1.025)
Blood, UA Large
PH, Urine 7.0 (5.0-8.0)
Leukocytes Small
Nitrites Positive
C&S results were not available yet.
TEMPLATE IN SEPARATE FILE:
Rubric Detail
Select Grid View or List View to change the rubric’s layout.
Name: NRNP_6540_Week7_Assignment_Rubric
• Grid View
• List View
Excellent Good Fair Poor
Create documentation in the Focused SOAP Note Template about the patient in the case study to which you were assigned.
In the Subjective section, provide:
• Chief complaint
• History of present illness (HPI)
• Current medications, checked against Beers Criteria
• Allergies
• Patient medical history (PMHx)
• Review of systems 9 (9%) – 10 (10%)
The 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. 8 (8%) – 8 (8%)
The 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. 7 (7%) – 7 (7%)
The 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. 0 (0%) – 6 (6%)
The 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.
In the Objective section, provide:
• Physical exam documentation of systems pertinent to the chief complaint, HPI, and history
• Diagnostic results, including any labs, imaging, or other assessments needed to develop the differential diagnoses 9 (9%) – 10 (10%)
The response thoroughly and accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are thoroughly and accurately documented. 8 (8%) – 8 (8%)
The response accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are accurately documented. 7 (7%) – 7 (7%)
Documentation of the patient’s physical exam is somewhat vague or contains minor innacuracies. Diagnostic tests and their results are documented but contain minor innacuracies. 0 (0%) – 6 (6%)
The response provides incomplete or inaccurate documentation of the patient’s physical exam. Systems may have been unnecessarily reviewed, or, objective documentation is missing.
In the Assessment section, provide:
• At least three (3) differentials with supporting evidence. Explain what rules each differential in or out, and justify your primary diagnosis selection. Include pertinent positives and pertinent negatives for the specific patient case. 23 (23%) – 25 (25%)
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. 20 (20%) – 22 (22%)
The 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. 18 (18%) – 19 (19%)
The 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. 0 (0%) – 17 (17%)
The 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.
In the Plan section, provide:
• 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.
• A discussion related to health promotion and disease prevention taking into consideration patient factors, PMH, and other risk factors.
• Reflections on the case describing insights or lessons learned. 27 (27%) – 30 (30%)
The 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. 24 (24%) – 26 (26%)
The 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. 21 (21%) – 23 (23%)
Name: NRNP_6540_Week7_Assignment_Rubric
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Focused SOAP Note Template
Patient Information:
Initials, Age, Sex, Race
S (subjective)
CC (chief complaint): a BRIEF statement identifying why the patient is here, stated in the patient’s own words (for instance “headache,” NOT “bad headache for 3 days”).
HPI (history of present illness): This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. Use LOCATES Mnemonic to complete your HPI. You need to start EVERY HPI with age, race, and gender (e.g., 34-year-old AA male). You must include the seven attributes of each principal symptom in paragraph form not a list. If the CC was “headache”, the LOCATES for the HPI might look like the following example:
• Location: Head
• Onset: 3 days ago
• Character: Pounding, pressure around the eyes and temples
• Associated signs and symptoms: Nausea, vomiting, photophobia, phonophobia
• Timing: After being on the computer all day at work
• Exacerbating/relieving factors: Light bothers eyes; Aleve makes it tolerable but not completely better
• Severity: 7/10 pain scale
Current Medications: Include dosage, frequency, length of time used, and reason for use; also include over the counter (OTC) or homeopathic products.
Allergies: Include medication, food, and environmental allergies separately, including a description of what the allergy is (i.e., angioedema, anaphylaxis, etc.). This will help determine a true reaction versus intolerance.
PMHx: Include immunization status (note date of last tetanus for all adults), past major illnesses, and surgeries. Depending on the CC, more info is sometimes needed.
Soc 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.
Fam Hx: Illnesses with possible genetic predisposition, contagious, or chronic illnesses. Reason for death of any deceased first-degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent.
Surgical Hx: Prior surgical procedures.
Mental Hx: Diagnosis and treatment. Current concerns (anxiety and/or depression). History of self-harm practices and/or suicidal or homicidal ideation.
Violence Hx: Concern or issues about safety (personal, home, community, sexual (current and historical).
Reproductive Hx: Menstrual history (date of LMP), Pregnant (yes or no), Nursing/lactating (yes or no), contraceptive use (method used), types of intercourse (oral, anal, vaginal, other, any sexual concerns).
ROS (review of symptoms): Cover all body systems that may help you include or rule out a differential diagnosis You should list each system as follows:
• General:
• Head:
• EENT (eyes, ears, nose, and throat):
• Etc.:
Note: You should list these in bullet format, and document the systems in order from head to toe.
Example of Complete ROS:
GENERAL: No weight loss, fever, chills, weakness, or fatigue.
HEENT:
• Eyes: No visual loss, blurred vision, double vision or yellow sclerae.
• Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.
SKIN: No rash or itching.
CARDIOVASCULAR: No chest pain, chest pressure or chest discomfort. No palpitations or edema.
RESPIRATORY: No shortness of breath, cough or sputum.
GASTROINTESTINAL: No anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.
GENITOURINARY: Burning on urination. Last menstrual period (LMP), MM/DD/YYYY.
NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.
MUSCULOSKELETAL: No muscle, back pain, joint pain or stiffness.
HEMATOLOGIC: No anemia, bleeding or bruising.
LYMPHATICS: No enlarged nodes. No history of splenectomy.
PSYCHIATRIC: No history of depression or anxiety.
ENDOCRINOLOGIC: No reports of sweating, cold or heat intolerance. No polyuria or polydipsia.
REPRODUCTIVE: Not pregnant and no recent pregnancy. No reports of vaginal or penile discharge. Not sexually active.
ALLERGIES: No history of asthma, hives, eczema or rhinitis.
O (objective)
Physical exam: From head-to-toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History. Do not use “WNL” or “normal.” You must describe what you see. Always document in head to toe format (i.e., General: Head: EENT: etc.).
Diagnostic results: Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines).
A (assessment)
Differential diagnoses: List a minimum of three differential diagnoses. Your primary or presumptive diagnosis should be at the top of the list. For each diagnosis, provide supportive documentation with evidence-based guidelines.
P (plan)
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. Each diagnosis or condition documented in the assessment should be addressed in the plan. The details of the plan should follow an orderly manner.
Also included in this section is the reflection. Reflect on this case, and discuss what you learned, including any “aha” moments or connections you made.
Also include in your reflection, a discussion related to health promotion and disease prevention taking into consideration patient factors (such as, age, ethnic group, etc.), PMH, and other risk factors (e.g., socio-economic, cultural background, etc.).
References
You are required to include 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 to use correct APA 7th edition formatting.
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DIFFERENTIAL DIAGNOSIS AND TREATMENT OF UROLOGICAL AND GYNECOLOGICAL DISEASES
For an older adult, a detailed history of abdominal, urological, and gynecological problems is required. Consider how you could evaluate and treat older adult patients who present with abdominal, urological, or gynecological issues. Prep:
Review your instructor’s case study.
Consider the patient’s symptoms and any underlying illnesses.
Consider how you may assess, diagnose, and treat people with the symptoms in this situation.
RESOURCES REQUIRED
L. Kennedy-Malone, L. Martin-Plank, & E. Duffy (2019). Urogynecological diseases Advanced practice nursing in aging (2nd ed., pp. 280–304). DAVIS, F.
L Demarest (2019). What is an overactive bladder? Nursing Made Simple, 17(4), 11–14. https://doi.org/10.1097/01.NME.0000559586.35631.37
P. Jackson & C. M. Vigiola (2018). GI obstruction: diagnosis and treatment AFM, 98(6), 362–367.
Shian, B., S. T. Larson (2018). Pain in the abdominal wall: examination, diagnosis, and therapy AFM 98(7), 429–436.
OTHER SUPPORT:
(Producer) (2017e). Access and payment for senior community services [Video]. https://engageil.com/modules/community-services-for-the-older-adult-access-and-payment-systems/
Note: View the free Community Services for the Elderly: Access and Payment Systems video module.
Engage-IL (Producer). (2017x). Culturally competent care for LGBTQ seniors [Video]. https://engageil.com/modules/primary-care-best-practices-for-lgbtq-older-adults /
View the free video module Providing Culturally Appropriate Care for LGBTQ Older Adults.
Engage-IL (Producer). (2017y). Sexuality and Aging [Video]. https://engageil.com/modules/sexuality-and-the-older-adult/
View the free course’s video module on Sexuality with Older Adults.
INSTRUCTIONS::::!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
For further information, see this week’s Resources. Make sure track changes is off: see doc sharing. Please remove all extra wording and instructions from the SOAP WORD DOCUMENT.
The Task: The case study patient’s Focused SOAP Note Template is provided. Address the following:
Subjective: How did the patient feel? What information did the patient disclose about their current disease, personal and medical history? Include a list of current prescription and OTC medications. Compare this list to the AGS Beers Criteria® and investigate alternatives. Review systems.
What did you notice during the physical exam? Was the lab, imaging, or functional testing resulted?
Provide three differential diagnosis. Prioritize them from highest to lowest. Compare the diagnostic criteria for each differential and explain why. Describe your critical thinking process that led to your primary diagnosis. Include the patient’s specific positives and negatives.
Plan: Give the patient a clear treatment plan that addresses each diagnosis. Be sure to capture the results of any diagnostic tests, referrals to other health care professionals and any planned follow-up appointments. Discuss with the patient health promotion and illness prevention, taking into account patient variables, past medical history, and other risk factors. Finally, include a case reflection statement describing key takeaways.
Cite at least three peer-reviewed journal papers or evidence-based guidelines that support your diagnosis and differential diagnoses in this instance. Ensure they are up-to-date (less than 5 years old) and complement the treatment strategy. Format in APA 7th edition.
VIRTUALIZED SOAP NOTES Please complete any gaps. Nullify the information on your soap note. You fill in the blanks with previous patient encounters. Missing information reduces points. *Remember that all soap notes must promote patient health. The name, method, dose, duration, and stop date of drugs are also necessary. This is crucial in acute care.
REVIEW THE CASE STUDY PROVIDED BY YOUR INSTRUCTOR.
• Consider the patient’s symptoms and any underlying diseases.
• Consider how you may assess, diagnose, and treat patients with the symptoms in this situation.
Obtain this week’s Focused SOAP Note Template.
The Task:
The case study patient’s Focused SOAP Note Template is provided. Address the following:
In what way did the patient feel? What information did the patient disclose about their current disease, personal and medical history? Include a list of current prescription and OTC medications. Compare this list to the AGS Beers Criteria® and investigate alternatives. Review systems.
• Objective: What did the physical assessment reveal? Was the lab, imaging, or functional testing resulted?
• Assessment: Provide three differential diagnoses. Prioritize them from highest to lowest. Compare the diagnostic criteria for each differential and explain why. Describe your critical thinking process that led to your primary diagnosis. Include the patient’s specific positives and negatives.
• Plan: Create a treatment plan for the patient that addresses all diagnoses. Be sure to capture the results of any diagnostic tests, referrals to other health care professionals and any planned follow-up appointments. Discuss with the patient health promotion and illness prevention, taking into account patient variables, past medical history, and other risk factors. Finally, include a case reflection statement describing key takeaways.
•
Cite at least three peer-reviewed journal papers or evidence-based guidelines that support your diagnosis and differential diagnoses in this instance. Ensure they are up-to-date (less than 5 years old) and complement the treatment strategy. Format in APA 7th edition.
