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:
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%)
The 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. 0 (0%) – 20 (20%)
The 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.
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. 9 (9%) – 10 (10%)
The 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. 8 (8%) – 8 (8%)
The 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. 7 (7%) – 7 (7%)
Three evidence-based resources are provided to support treatment decisions, but may not represent the latest in standards of care or
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 (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. 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. 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 is vague or off topic. 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.
Written Expression and Formatting—English writing standards:
Correct grammar, mechanics, and proper punctuation 5 (5%) – 5
Contains many (≥ five) grammar, spelling, and punctuation errors that interfere with the reader’s understanding.
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 (5%) – 5 (5%)
Uses correct APA format with no errors. 4 (4%) – 4 (4%)
Contains a few (one or two) APA format errors. 3 (3%) – 3 (3%)
Contains several (three or four) APA format errors. 0 (0%) – 2 (2%)
Contains many (≥ five) APA format errors.
Total Points: 100
Name: NRNP_6540_Week7_Assignment_Rubric
Sample answer Focused SOAP Note
Patient Information:
R.B. 95-year-old, white,
S (subjective)
CC (chief complaint): “My urine is really red.”
HPI (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.
Current 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.
Allergies: Penincilin and hives
PMHx: 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.
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: Married and widowed. Children and grandchildren are alive. Lives in a nursing home.
Surgical Hx: Splenectomy at 55 years.
Mental Hx: History of depression and suicidal ideation. Treated with no reoccurrence.
Violence Hx: No history of violence self-harm.
Reproductive Hx: Not sexually active. Has three daughters.
ROS (review of symptoms):
GENERAL: No unintentional weight changes or fever.
HEENT:
• Eyes: No visual loss or watery eyes.
• Ears, Nose, Throat: No hearing loss, congestion of the nose, or sore throat.
SKIN: No rashes.
CARDIOVASCULAR: No palpitation or edema.
RESPIRATORY: No shortness of breath.
GASTROINTESTINAL: No nausea or vomiting.
GENITOURINARY: Urine is red.
NEUROLOGICAL: No headache or changes in bladder control.
MUSCULOSKELETAL: No back pain or muscle stiffness.
HEMATOLOGIC: No bleeding.
LYMPHATICS: History of splenectomy.
PSYCHIATRIC: History of depression or anxiety.
ENDOCRINOLOGIC: No sweating.
REPRODUCTIVE: Not sexually active.
ALLERGIES: Penicillin and hives.
O (objective)
Physical exam:
Vital signs: BP 122/70, HR 66, Temp 98.0 F, Resp 18, Pulse ox 98.
Diagnostic results:
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
A (assessment)
Differential diagnoses:
Cancerous and noncancerous tumors
A 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).
Urinary tract infection (UTI)
UTI 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).
Kidney cysts
Kidney 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).
P (plan)
The 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.
I 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.
The 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.
References
Alaygut, D., Erfidan, G., Soyaltın, E., Siviş, Z. Ö., Çamlar, S. A., Mutlubaş, 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.
Cavanaugh, 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.
McIntire, P. J., Kilic, I., Wojcik, E. M., Barkan, G. A., & Pambuccian, S. E. (2020). The color of urine: then and now—a 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.
