WEEK 7: Task: Assessing, Diagnosing, and Treating Stomach, Urological, and Gynecological Issues
Correct historical past taking of belly, urological, and gynecological complaints is important for finishing an Assessment of the older grownup. For this Task, as you study this week’s affected person case research, think about the way you would possibly consider and deal with older grownup sufferers who current with well being issues associated to the belly, urological, or gynecological To arrange:
Assessment the case research supplied by your Teacher.
Mirror on the affected person’s signs and elements of problems that could be current.
Contemplate the way you would possibly assess, carry out diagnostic exams, and advocate medicines to deal with sufferers presenting with the signs within the case.
RESOURCES:
REQUIRED RESOURCES
Kennedy-Malone, L., Martin-Plank, L., & Duffy, E. (2019). Urological and gynecological problems. In Superior follow nursing within the care of older adults (2nd ed., pp. 280–304). F. A. Davis.
Demarest, L. (2019). Gotta go proper now: What’s overactive bladder? Nursing Made Extremely Simple!, 17(Four), 11–14. https://doi.org/10.1097/01.NME.0000559586.35631.37
Jackson, P., & Vigiola, C. M. (2018). Intestinal obstruction: Analysis and administration. American Household Doctor, 98(6), 362–367.
Shian, B., & Larson, S. T. (2018). Stomach wall ache: Medical analysis, differential prognosis, and remedy. American Household Doctor, 98(7), 429–436.
OTHER RESOURCES:
Have interaction-IL (Producer). (2017e). Neighborhood companies for the older grownup: Entry and cost techniques [Video]. https://engageil.com/modules/community-services-for-the-older-adult-access-and-payment-systems/
Observe: View the Neighborhood Companies for the Older Grownup: Entry and Fee Programs video module out there on this free course.
Have interaction-IL (Producer). (2017x). Offering culturally acceptable take care of LGBTQ older adults [Video]. https://engageil.com/modules/primary-care-best-practices-for-lgbtq-older-adults/
Observe: View the Offering Culturally Acceptable Look after LGBTQ Older Adults video module out there on this free course.
Have interaction-IL (Producer). (2017y). Sexuality and the older grownup [Video]. https://engageil.com/modules/sexuality-and-the-older-adult/
Observe: View the Sexuality and the Older Grownup video module out there on this free course.
INSTRUCTIONS::::!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
Entry the Centered SOAP Observe Template on this week’s Sources. Make certain monitor adjustments are OFF: see the directions 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 Task: Full the Centered SOAP Observe Template supplied for the affected person within the case research. Make sure to tackle the next:
Subjective: What was the affected person’s subjective criticism? What particulars did the affected person present concerning their historical past of current sickness and private and medical historical past? Embody an inventory of prescription and over-the-counter medicine the affected person is at the moment taking. Evaluate this listing to the American Geriatrics Society Beers Standards® and think about various medicine if acceptable. Present a Assessment of techniques.
Goal: What observations did you word from the bodily Assessment? What have been the lab, imaging, or useful assessments outcomes?
Assessment: Present a minimal of three differential diagnoses. Record them from prime precedence to least precedence. Evaluate the diagnostic standards for every and clarify what guidelines every differential in or out. Clarify you important considering course of that led you to the first prognosis you chose. Embody pertinent positives and pertinent negatives for the particular affected person case.
Plan: Present an in depth remedy plan for the affected person that addresses every prognosis, as relevant. Embody documentation of diagnostic research that might be obtained, referrals to different health-care suppliers, therapeutic interventions, training, disposition of the affected person, caregiver Help, and any deliberate follow-up visits. Present a dialogue of well being promotion and illness prevention for the affected person, bearing in mind affected person elements, previous medical historical past (PMH), and different threat elements. Lastly, embody a mirrored image assertion on the case that describes insights or classes discovered.
Present at the least three evidence-based peer-reviewed journal articles or evidenced-based tips, which relate to this case to Help your diagnostics and differentials diagnoses. Make certain they’re present (not more than 5 years previous) and Help the remedy plan in following present requirements of care. Observe APA seventh version formatting.
NOTE: SOAP notes are digital. Please fill in any lacking info. Don’t write in your cleaning soap word “info lacking”. You fill this info in out of your previous experiences with sufferers. Factors are deducted for lacking info. *keep in mind all cleaning soap notes should include affected person well being promotion and training. ALSO: if you happen to prescribe medicines, the identify, route, dose, length, and cease date is required. This is particularly necessary in acute care.
MORE DETAIL ON INSTRUCTIONS
o put together:
• Assessment the case research supplied by your Teacher.
• Mirror on the affected person’s signs and elements of problems that could be current.
• Contemplate the way you would possibly assess, carry out diagnostic exams, and advocate medicines to deal with sufferers presenting with the signs within the case.
• Entry the Centered SOAP Observe Template on this week’s Sources.
The Task:
Full the Centered SOAP Observe Template supplied for the affected person within the case research. Make sure to tackle the next:
• Subjective: What was the affected person’s subjective criticism? What particulars did the affected person present concerning their historical past of current sickness and private and medical historical past? Embody an inventory of prescription and over-the-counter medicine the affected person is at the moment taking. Evaluate this listing to the American Geriatrics Society Beers Standards®, and think about various medicine if acceptable. Present a Assessment of techniques.
• Goal: What observations did you word from the bodily Assessment? What have been the lab, imaging, or useful assessments outcomes?
• Assessment: Present a minimal of three differential diagnoses. Record them from prime precedence to least precedence. Evaluate the diagnostic standards for every, and clarify what guidelines every differential in or out. Clarify you important considering course of that led you to the first prognosis you chose. Embody pertinent positives and pertinent negatives for the particular affected person case.
• Plan: Present an in depth remedy plan for the affected person that addresses every prognosis, as relevant. Embody documentation of diagnostic research that might be obtained, referrals to different health-care suppliers, therapeutic interventions, training, disposition of the affected person, caregiver Help, and any deliberate follow-up visits. Present a dialogue of well being promotion and illness prevention for the affected person, bearing in mind affected person elements, previous medical historical past (PMH), and different threat elements. Lastly, embody a mirrored image assertion on the case that describes insights or classes discovered.
• Present at the least three evidence-based peer-reviewed journal articles or evidenced-based tips, which relate to this case to Help your diagnostics and differentials diagnoses. Make certain they’re present (not more than 5 years previous) and Help the remedy plan in following present requirements of care. Observe APA seventh version formatting.
THE CASE SOAP NOTE:
Week 7: Stomach, Urinary, and Gynecological
Case 1: UTI
R.B. 95-year-old, white male, at the moment residing in a talented nursing facility (SNF)
Chief criticism: “My urine is really crimson.”
HPI: On Wednesday (2 days in the past) the affected person was delivered to your clinic by his son and complained that his urine gave the impression to be shiny crimson in coloration. You ordered labs, urinalysis, tradition, and sensitivity, and the outcomes are under.
Allergy symptoms: Penicillin: Hives
Drugs: Tamsulosin Zero.Four mcg, 2 capsules each day, Aspirin 325 mg each day, Atorvastatin 10 mg 1 pill each day, Donepezil 10 mg 1 pill PO QHS, Metoprolol 25 mg Zero.5 mg pill each 12 hours, Acetaminophen 500 mg 1 pill BID
Code standing: DNR Common eating regimen, pureed texture, honey-thickened liquids
Vitals: BP 122/70, HR 66, Temp 98.Zero F, Resp 18, Pulse ox 98% Weight:____ BMI:____
PMH: Cognitive communication deficit, pneumonitis on account of inhalation of meals and vomit, dysphagia, R-side hemiplegia and hemiparesis previous ischemic CVA, reasonable vascular dementia, malignant neoplasm of prostate, new-onset atrial fibrillation (12/2019), DVT on left decrease extremity, gross hematuria
Labs:
RBC three.53 (L)
Hemoglobin 10.2 (L)
Microscopic Assessment, Urine, straight Cath
Part:
WBC UA 42 (H) (Zero-5/ HPF)
RBC, UA >900 (H) (Zero-5/HPF)
Epithelial cells, urine 2 (Zero-Four /HPF)
Hyaline casts, UA Zero (Zero-2 /LPF)
Urinalysis
Shade Crimson
Look (Urine) Clear
Ketones, UA Hint
Particular gravity 1.Zero20 (1.005-1.Zero25)
Blood, UA Massive
PH, Urine 7.Zero (5.Zero-Eight.Zero)
Leukocytes Small
Nitrites Optimistic
C&S outcomes weren’t out there but.
TEMPLATE IN SEPARATE FILE:
Rubric Element
Choose Grid View or Record View to vary the rubric’s format.
Title: NRNP_6540_Week7_Assignment_Rubric
• Grid View
• Record View
Wonderful Good Honest Poor
Create documentation within the Centered SOAP Observe Template in regards to the affected person within the case research to which you have been assigned.
Within the Subjective part, present:
• Chief criticism
• Historical past of current sickness (HPI)
• Present medicines, checked towards Beers Standards
• Allergy symptoms
• Affected person medical historical past (PMHx)
• Assessment of techniques 9 (9%) – 10 (10%)
The response throughly and precisely describes the affected person’s subjective criticism, historical past of current sickness, present medicines, allergy symptoms, medical historical past, and Assessment of all techniques that will inform a differential prognosis. An intensive cross-check of medicines towards the Beers Standards has been accomplished and acceptable various medicine really helpful if relevant. Eight (Eight%) – Eight (Eight%)
The response precisely describes the affected person’s subjective criticism, historical past of current sickness, present medicines, allergy symptoms, medical historical past, and Assessment of all techniques that will inform a differential prognosis. A cross-check of medicines towards the Beers Standards has been accomplished and acceptable various medicine really helpful if relevant. 7 (7%) – 7 (7%)
The response describes the affected person’s subjective criticism, historical past of current sickness, present medicines, allergy symptoms, medical historical past, and Assessment of all techniques that will inform a differential prognosis, however is considerably obscure or accommodates minor innacuracies. A cross-check of medicines towards the Beers Standards has been accomplished however options could also be lacking. Zero (Zero%) – 6 (6%)
The response gives an incomplete or inaccurate description of the affected person’s subjective criticism, historical past of current sickness, present medicines, allergy symptoms, medical historical past, and Assessment of all techniques that will inform a differential prognosis. A cross-check of medicines towards the Beers Standards has not been accomplished. Or, subjective documentation is lacking.
Within the Goal part, present:
• Bodily examination documentation of techniques pertinent to the chief criticism, HPI, and historical past
• Diagnostic outcomes, together with any labs, imaging, or different assessments wanted to develop the differential diagnoses 9 (9%) – 10 (10%)
The response totally and precisely paperwork the affected person’s bodily examination for pertinent techniques. Diagnostic exams and their outcomes are totally and precisely documented. Eight (Eight%) – Eight (Eight%)
The response precisely paperwork the affected person’s bodily examination for pertinent techniques. Diagnostic exams and their outcomes are precisely documented. 7 (7%) – 7 (7%)
Documentation of the affected person’s bodily examination is considerably obscure or accommodates minor innacuracies. Diagnostic exams and their outcomes are documented however include minor innacuracies. Zero (Zero%) – 6 (6%)
The response gives incomplete or inaccurate documentation of the affected person’s bodily examination. Programs could have been unnecessarily reviewed, or, goal documentation is lacking.
Within the Assessment part, present:
• Not less than three (three) differentials with supporting proof. Clarify what guidelines every differential in or out, and justify your main prognosis choice. Embody pertinent positives and pertinent negatives for the particular affected person case. 23 (23%) – 25 (25%)
The response lists so as of precedence at the least three distinctly completely different and detailed potential situations for a differential prognosis of the affected person within the assigned case research, and gives a radical, correct, and detailed justification for every of the situations chosen. 20 (20%) – 22 (22%)
The response lists so as of precedence at the least three completely different potential situations for a differential prognosis of the affected person within the assigned case research and gives an correct justification for every of the situations chosen. 18 (18%) – 19 (19%)
The response lists three potential situations for a differential prognosis of the affected person within the assigned case research, with some vagueness and/or inaccuracy within the situations and/or justification for every. Zero (Zero%) – 17 (17%)
The response lists two or fewer, or is lacking, potential situations for a differential prognosis of the affected person within the assigned case research, with inaccurate or lacking justification for every situation chosen.
Within the Plan part, present:
• An in depth remedy plan for the affected person that addresses every prognosis, as relevant. Contains documentation of diagnostic research that might be obtained, referrals to different health-care suppliers, therapeutic interventions, training, disposition of the affected person, and any deliberate comply with up visits.
• A dialogue associated to well being promotion and illness prevention bearing in mind affected person elements, PMH, and different threat elements.
• Reflections on the case describing insights or classes discovered. 27 (27%) – 30 (30%)
The response totally and precisely outlines a remedy plan for the affected person that addresses every prognosis and contains diagnostic research neeed, referrals, therapeutic interventions, affected person training and disposition, and deliberate follow-up visits. An intensive and correct dialogue of well being promotion and illness prevention associated to the case is supplied. Reflections on the case reveal robust important considering and synthesis of concepts. 24 (24%) – 26 (26%)
The response precisely outlines a remedy plan for the affected person that addresses every prognosis and contains diagnostic research neeed, referrals, therapeutic interventions, affected person training and disposition, and deliberate follow-up visits. An correct dialogue of well being promotion and illness prevention associated to the case is supplied. Reflections on the case reveal important considering. 21 (21%) – 23 (23%)
The response considerably vaguely or inaccurately outlines a remedy plan for the affected person. The dialogue on well being promotion and illness prevention associated to the case is considerably obscure or accommodates innaccuracies. Reflections on the case reveal satisfactory understanding after all matters. Zero (Zero%) – 20 (20%)
The response doesn’t tackle all diagnoses or is lacking components of the remedy plan. The dialogue on well being promotion and illness prevention associated to the case is obscure, innaccurate, or lacking. Reflections on the case are obscure or lacking.
Present at the least three evidence-based peer-reviewed journal articles or evidenced-based tips which relate to this case to Help your diagnostics and differentials diagnoses. Make certain they’re present (not more than 5 years previous) and Help the remedy plan in following present requirements of care. 9 (9%) – 10 (10%)
The response gives at the least three present, evidence-based sources from the literature to Help the remedy plan for the affected person within the assigned case research. Every useful resource represents the newest in requirements of care and gives robust justification for remedy choices. Eight (Eight%) – Eight (Eight%)
The response gives at the least three present, evidence-based sources from the literature to Help the remedy plan for the affected person within the assigned case research. Every useful resource represents present requirements of care and helps remedy choices. 7 (7%) – 7 (7%)
Three evidence-based sources are supplied to Help remedy choices, however could not signify the newest in requirements of care or could solely present obscure or weak justification for the remedy plan. Zero (Zero%) – 6 (6%)
Two or fewer sources are supplied to Help remedy choices. The sources might not be present or evidence-based, or don’t Help the remedy plan.
Written Expression and Formatting—Paragraph Improvement and Group:
Paragraphs clarify factors that Help well-developed concepts, circulation logically, and reveal continuity of concepts. Sentences are fastidiously focused–neither lengthy and rambling nor quick and missing substance. A transparent and complete objective assertion and introduction are supplied that delineate all required standards. 5 (5%) – 5 (5%)
Paragraphs and sentences comply with writing requirements for circulation, continuity, and readability.
A transparent and complete objective assertion, introduction, and conclusion are supplied that delineate all required standards. Four (Four%) – Four (Four%)
Paragraphs and sentences comply with writing requirements for circulation, continuity, and readability 80% of the time.
Objective, introduction, and conclusion of the project are said, but are temporary and never descriptive. three (three%) – three (three%)
Paragraphs and sentences comply with writing requirements for circulation, continuity, and readability 60%–79% of the time.
Objective, introduction, and conclusion of the project is obscure or off subject. Zero (Zero%) – 2 (2%)
Paragraphs and sentences comply with writing requirements for circulation, continuity, and readability < 60% of the time.
—
Centered SOAP Observe
Pupil’s Title
Institutional Affiliation
Course
Professor’s Title
Date
Affected person Data:
R.B. 95-year-old, white,
S (subjective)
CC (chief criticism): “My urine is really crimson.”
HPI (historical past of current sickness): R.B. 95-year-old, white male, at the moment residing in a talented nursing facility (SNF). On Wednesday (2 days in the past) the affected person was delivered to your clinic by his son and complained that his urine gave the impression to be shiny crimson in coloration. You ordered labs, urinalysis, tradition, and sensitivity, and the outcomes are under.
Present Drugs: Tamsulosin Zero.Four mcg, 2 capsules each day, Aspirin 325 mg each day, Atorvastatin 10 mg 1 pill each day, Donepezil 10 mg 1 pill PO QHS, Metoprolol 25 mg Zero.5 mg pill each 12 hours, Acetaminophen 500 mg 1 pill BID.
Allergy symptoms: Penincilin and hives
PMHx: Cognitive communication deficit, pneumonitis on account of inhalation of meals and vomit, dysphagia, R-side hemiplegia and hemiparesis previous ischemic CVA, reasonable vascular dementia, malignant neoplasm of prostate, new-onset atrial fibrillation (12/2019), DVT on left decrease extremity, gross hematuria.
Soc and Substance Hx: Embody occupation and main hobbies, household standing, tobacco and alcohol use (earlier and present use), and every other pertinent knowledge. All the time add some well being promo Question Assignment right here, reminiscent of whether or not they use seat belts on a regular basis or whether or not they have working smoke detectors in the home, residing surroundings, textual content/cellphone use whereas driving, and Help system.
Fam Hx: Married and widowed. Youngsters and grandchildren are alive. Lives in a nursing dwelling.
Surgical Hx: Splenectomy at 55 years.
Psychological Hx: Historical past of melancholy and suicidal ideation. Handled with no reoccurrence.
Violence Hx: No historical past of violence self-harm.
Reproductive Hx: Not sexually energetic. Has three daughters.
ROS (Assessment of signs):
GENERAL: No unintentional weight adjustments or fever.
HEENT:
• Eyes: No visible loss or watery eyes.
• Ears, Nostril, Throat: No listening to loss, congestion of the nostril, or sore throat.
SKIN: No rashes.
CARDIOVASCULAR: No palpitation or edema.
RESPIRATORY: No shortness of breath.
GASTROINTESTINAL: No nausea or vomiting.
GENITOURINARY: Urine is crimson.
NEUROLOGICAL: No headache or adjustments in bladder management.
MUSCULOSKELETAL: No again ache or muscle stiffness.
HEMATOLOGIC: No bleeding.
LYMPHATICS: Historical past of splenectomy.
PSYCHIATRIC: Historical past of melancholy or anxiousness.
ENDOCRINOLOGIC: No sweating.
REPRODUCTIVE: Not sexually energetic.
ALLERGIES: Penicillin and hives.
O (goal)
Bodily examination:
Important indicators: BP 122/70, HR 66, Temp 98.Zero F, Resp 18, Pulse ox 98.
Diagnostic outcomes:
Labs:
RBC three.53 (L)
Hemoglobin 10.2 (L)
Microscopic Assessment, Urine, straight Cath
Part:
WBC UA 42 (H) (Zero-5/ HPF)
RBC, UA >900 (H) (Zero-5/HPF)
Epithelial cells, urine 2 (Zero-Four /HPF)
Hyaline casts, UA Zero (Zero-2 /LPF)
Urinalysis
Shade Crimson
Look (Urine): Clear
Ketones, UA Hint
Particular gravity 1.Zero20 (1.005-1.Zero25)
Blood, UA Massive
PH, Urine 7.Zero (5.Zero-Eight.Zero)
Leukocytes Small
Nitrites Optimistic
A (Assessment)
Differential diagnoses:
Cancerous and noncancerous tumors
A tumor within the urinary system may cause a change within the coloration of the urine. Aged folks above 50 years have a tumor or adjustments in urine coloration on account of an enlarged prostate gland (McIntire et al., 2020).
Urinary tract an infection (UTI)
UTI is an an infection of the urinary system inflicting crimson coloration on the urine. Signs of UTI embody intense urge to pee, darkish or crimson coloration of the urine, fever, or chills. Sufferers with UTI require pressing care (Cavanaugh & Perazella, 2019).
Kidney cysts
Kidney cysts could trigger no adversarial signs however sufferers can expertise crimson urine if the cysts burst. Sufferers with kidney cysts are more likely to expertise intense and frequent urges to urinate (Alaygut et al., 2021).
P (plan)
The affected person needs to be referred for an X-ray and extra examination of the urine to find out the suitable prognosis. The affected person ought to begin taking treatment and report back to the clinic after two weeks.
I discovered that aged males are vulnerable to the enlarged prostate gland which will increase the danger of crimson and darkish urine. It is important to diagnose the affected person to make sure acceptable remedy.
The affected person ought to drink ample water each day and keep away from exhausting duties that will trigger sweating. It is necessary to eat a nutritious diet to spice up immunity. The practitioner ought to keep confidentiality within the supply of care.
References
Alaygut, D., Erfidan, G., Soyaltın, E., Siviş, Z. Ö., Çamlar, S. A., Mutlubaş, F., & Demir, B. Okay. (2021). What does acute kidney harm and darkish red-brown urine that seem after bone marrow transplantation inform us: Questions. Pediatric Nephrology, 36(1), 65-66.
Cavanaugh, C., & Perazella, M. A. (2019). Urine sediment examination within the prognosis and administration of kidney illness: core curriculum 2019. American Journal of Kidney Illnesses, 73(2), 258-272.
McIntire, P. J., Kilic, I., Wojcik, E. M., Barkan, G. A., & Pambuccian, S. E. (2020). The colour of urine: then and now—a complete Assessment of the literature with emphasis on intracytoplasmic pigments encountered in urinary cytology. Journal of the American Society of Cytopathology, 9(1), 9-19.
—
