Obstetrics Comprehensive Patient Assessment.

When completing practicum requirements in clinical settings, you and your Preceptor might complete several patient assessments in the course of a day or even just a few hours. This schedule does not always allow for a thorough discussion or reflection on every patient you have seen. As a future advanced practice nurse, it is important that you take the time to reflect on a comprehensive patient assessment that includes everything from patient medical history to evaluations and follow-up care. For this Assignment, you begin to plan and write a comprehensive assessment that focuses on one female patient from your current practicum setting.Obstetrics Comprehensive Patient Assessment.

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To prepare

• Reflect on your Practicum Experience and select a female patient whom you have examined with the support and guidance of your Preceptor.
• Think about the details of the patient’s background, medical history, physical exam, labs and diagnostics, diagnosis, treatment and management plan, as well as education strategies and follow-up care.Obstetrics Comprehensive Patient Assessment.

To complete

Write an 8- to 10-page comprehensive assessment that addresses the following:

• Age, race and ethnicity, and partner status of the patient
• Current health status, including chief concern or complaint of the patient
• Contraception method (if any)
• Patient history, including medical history, family medical history, gynecologic history, obstetric history, and personal social history (as appropriate to current problem)
• Review of systems
• Physical exam
• Labs, tests, and other diagnostics
• Differential diagnoses
• Management plan, including diagnosis, treatment, patient education, and follow-up care

References

Learning Resources

Schuiling, K. D., & Likis, F. E. (2017). Women’s  gynecologic health (3rd ed.). Burlington, MA: Jones and Bartlett  Publishers.

Chapter 5, “Gynecologic Anatomy and Physiology” (pp. 77-93)
This chapter explores female anatomy and physiology with a focus on the female reproductive anatomy. It also describes the physiology of the menstrual cycle, including the hormonal feedback system and the ovarian and endometrial cycles.Obstetrics Comprehensive Patient Assessment.Obstetrics Comprehensive Patient Assessment.

Chapter 6, “Gynecologic History and Physical Examination” (pp. 95-133)
This chapter identifies the core knowledge and skill base required for obtaining a gynecologic health history and performing physical examinations such as pelvic and breast exams.

Chapter 7, “Periodic Screening and Health Maintenance” (pp. 135-149)
This chapter explores preventive health services for women such as screening tests, counseling, immunization, and chemoprevention. It also compares screening recommendations from organizations such as the U.S. Preventive Services Task Force, American College of Obstetricians and Gynecologists, and American Cancer Society.Obstetrics Comprehensive Patient Assessment.

Chapter 13, “Intimate Partner Violence” (pp. 303-322)
This chapter defines intimate partner violence (IPV) and describes the epidemiology and health effects of IPV. It also examines screening tools for assessing IPV and strategies for managing patients experiencing IPV, particularly pregnant women, adolescents, and older women.Obstetrics Comprehensive Patient Assessment.Obstetrics Comprehensive Patient Assessment.

Chapter 14, “Sexual Assault” (pp. 327-349)
This chapter examines strategies for identifying sexual violence and providing care to women who are victims of sexual violence. It explores potential health consequences of sexual violence on women, including physical injury, spread of sexually transmitted diseases, and unintended pregnancy.

Tharpe, N. L., Farley, C., & Jordan, R. G. (2017). Clinical practice guidelines for midwifery & women’s health (5th  ed.). Burlington, MA: Jones & Bartlett Publishers.
Chapter 6, “Care of the Well Woman Across the Life Span”
“Primary Preventive” Health Care for Well Women” (pp. 301-303)Obstetrics Comprehensive Patient Assessment.
This section examines social, mental, and physical issues that affect women during different stages of their lives. It also examines the provider’s role in prevention and care.
“Care of the Well Woman: Health Assessment and Screening for Women of Childbearing Age” (pp. 303-310)
This section provides a list of health information for the health care provider to address during well-woman examinations, as well as an immunization schedule for women across the life span.
“Care of the Well Woman: Health Assessment and Screening During Menopause” (pp. 338-349)
This section explains the physiologic changes that occur during menopause, including health issues that are likely to present. It also examines treatment and management options related to diet, exercise, sleep, and sexual comfort.Obstetrics Comprehensive Patient Assessment.                   Chapter 8, “Primary Care in Midwifery and Women’s Health”
“Care of the Woman: Prevention of Osteoporosis” (pp. 576-584)Obstetrics Comprehensive Patient Assessment.
This section explores factors that increase risks of osteoporosis in women, particularly postmenopausal women. It also provides strategies for identifying risk factors of osteoporosis and diagnosing and treating the condition.
“Care of the Woman in Need of Smoking Cessation” (pp. 471-475)Obstetrics Comprehensive Patient Assessment.
This section outlines factors that impact successful smoking cessation. It also describes treatment options and patient education strategies for women in need of smoking cessation.Obstetrics Comprehensive Patient Assessment.Obstetrics Comprehensive Patient Assessment.

U.S. Department of Health and Human Services. (2012b). Screening tests and vaccines. Retrieved from http://www.womenshealth.gov/screening-tests-and-vaccines/screening-tests-for-women/

This article provides guidelines for recommended screening tests for women. The guidelines are categorized by age and type of test.

Obstetrics Comprehensive Patient Assessment.

Comprehensive Patient Assessment

The most import aspect of an accurate process of care delivery is a comprehensive assessment of the patient. Assessment makes it possible for the care provider to gather relevant information concerning the health condition of the patient thus creating the ground for appropriate intervention. Nurses have a general role to ensure the correct data concerning the health of a patient is recorded appropriately. This data is then analyzed to facilitate clinical decision-making (Linsley, Kane & Owen, 2011). Proper analysis of the health information is crucial in the determination of the conditions the patient is suffering from as well as the condition he/she is at risk of developing. A SOAP note is one of the documents containing the health information of a patient that guides clinicians in decision making. A soap note comprises of the current and past health information of the patient, the social and medical history as well as the history of hospitalization and medications used by the patient. This paper highlights a comprehensive assessment of a woman presenting with symptoms typical of Human papilloma virus.Obstetrics Comprehensive Patient Assessment.

SUBJECTIVE

Patient: _PT_ Age: _39 _ Gender: __F_ Marital status__Married_ Race __African American

Chief complaint: “I am here today due to rough though painless bumps on the pubic region together with general woman health examination.”

History of present illness

PT is a thirty-nine-year-old African America female patient who has visited the clinic complaining of painless pink bumps on the pubic area. The patient states that the bumps are shaped like cauliflower. The patient noted these warts three weeks ago but dismissed them as simple rashes caused by excessive heat. She is not sure for how long these bumps had existed before she noticed them. However, the patient makes it clear that she has not experienced abnormal vaginal discharge. The patient points out that the bumps have led to mild irritation, itching and burning sensation around the pubic area. She has tried to clean the affected area with warm water and soap, but the problem has persisted. The patient has also been experiencing pain in the vulva thus increasing the discomfort associated with these warts. The patient has not experienced any changes in urinary urge and frequency. Over the last, few days the discomfort associated with these warts have increased thus increasing the need for specialized care. Nonetheless, the patient has not taken any medication for the problem.Obstetrics Comprehensive Patient Assessment.

Past medical history

The patient was diagnosed with Chlamydia three years ago, which was effectively treated through administration of antibiotics- azithromycin. The problem cleared up in two weeks, and she has not been diagnosed with Chlamydia ever since. She was also diagnosed with bacterial vaginosis in 2012, but the condition was managed with metronidazole gel. The patient does not have a chronic condition such as diabetes, hypertension, or cerebral vascular accident. The patient makes it clear that she has not suffered from any health disorders related to inappropriate lifestyles such as substance abuse, alcoholism, consumption of junk foods, and cigarette smoking. However, the is vague when an inquiry is made concerning her sexual health. She notes that she has been in a monogamous family all through even though a month ago she was involved in a sexual relationship with a long time friend.Obstetrics Comprehensive Patient Assessment.

Immunization

The patient has an up to date immunization schedule. She received a tetanus shot together with a flu shot in June 2016.

Allergies: The patient has not been diagnosed with any form of allergic reaction.

Medications: none

Medication Intolerance: None

Chronic health problems: bacterial vaginosis and herpes simplex virus

Hospitalization and procedures: The patient has not been diagnosed with a condition requiring a surgical operation. Also, she has not been hospitalized previously. Comment by Grammarly: Deleted:In additi Comment by Grammarly: Deleted:n

Family medical history:

The patient’s family has a history of chronic disorders. His father was diagnosed with hypertension and diabetes mellitus, which are believed to be the leading causes of death. Her mother is still alive, but suffers from hypertension and chronic kidney stones; she also has a brother, who is asthmatic. However, the records of the health information of her grandparents cannot be traced.Obstetrics Comprehensive Patient Assessment.

Social history

Occupation: The patient works as a clerk at a local store.

Marital status: the patient has been married for the last 19 years and lives with her husband in their home.

Children: she is a mother of two boys aged 13 and 15 years.

Birth control: she uses condom as her main birth control method

Exercise: The patient engages in simple physical exercises once or twice every week. She also jogs and runs around for at least thirty minutes when she is off duty.

Alcohol and tobacco: the patient notes that she drinks alcohol occasionally, mostly during social events. She has never smoked cigarettes in her life.

Substance abuse: the patient denies involvement in any form of drugs and substance abuse.Obstetrics Comprehensive Patient Assessment.

Safety: the patient asserts that her home offers the security, social support, and environmental safety necessary for a family.

Review of systems

General: the patient states she has not experienced intense changes in weight; she also denies body weakness and fatigue, fever as well as chills.

Head: Her head is normal with no physical injuries or bruises

Eyes: The patient has not experienced any form of vision loss; he does not have blurred vision or double vision. She does not suffer from pain in the eyes, redness, or itching. The patient does not wear contacts and denies difficulty focusing, peripheral vascular changes, scotoma, diplopia, and dryness in the eyes.Obstetrics Comprehensive Patient Assessment.

Ears: she does not have hearing problems. The ears are also free of abnormal discharge. She states that she does not experience ear pain, ringing, or itching in the ears.

Nose/throat/mouth: the patient does not have a runny nose, and she does not experience nasal congestion and sneezing. She denies painful sensation in the throat, dryness in the mouth and hoarseness. Her oral mucosa is pink in color and moist.Obstetrics Comprehensive Patient Assessment.

Cardiovascular: the patient denies any form of a cardiovascular-related problem; she does not experience chest pain, discomfort, or unnecessary pressure. Also, she does not experience palpitations and edema. She does not have a history of varicose veins, dyspnea, heart murmurs, and activity intolerance.Obstetrics Comprehensive Patient Assessment.

Respiratory: she denies respiratory problems such as shortness of breath, dyspnea, wheezing, and coughing. Also, she does not experience increased production of sputum. She also denies a history of respiratory infections, exposure to smoke, pain on inspiration and exposure to TB. Comment by Grammarly: Deleted:In additi Comment by Grammarly: Deleted:n

Skin: The skin of the patient is dry and warm to the touch besides being free of rashes, bruises, injuries, and lesions. However, she has noted small bumps on the vulva and the skin around the external genitalia. She states she has been experiencing mild itching in the genital region.Obstetrics Comprehensive Patient Assessment.

Gastrointestinal: the patient reports good gastrointestinal health: she does not suffer from pain in the abdomen, nausea and vomiting, diarrhea and constipation, anorexia, and heartburn. The patient also denies changes in appetite, food intolerance and changes in bowel patterns as well as hemorrhoids and flatulence.Obstetrics Comprehensive Patient Assessment.

Genitourinary: the patient denies urinary incontinence, dysuria, and heavy bleeding. She has not experienced any changes in urinary urge and frequency. She denies burning sensation during urination. However, she has been experiencing mild pelvic pain and abnormal vaginal discharge. The patient is sexually active. She has not missed her menses.

Endocrine: the patient does not report any thyroid problems, heat and cold intolerance, excessive weight gain or loss, sweating, polydipsia, and polyuria. The patient does not use any form of hormonal therapy. No changes in facial and body hair, skin, and nails texture are reported.Obstetrics Comprehensive Patient Assessment.

Breast: The patient notes that she does not have lumps in the breasts. She does not experience breast pain, abnormal discharge, or soreness.

Musculoskeletal: She denies musculoskeletal pain, arthritis, and edema. She does not experience stiffness of the joints, mo report made on a history of gout, deformities, decreased strength, and swelling, as well as chronic low back pain and a decreased range of motion.

Neurological: the patient denies focal weakness, blackout, and seizures. She does not suffer from a depressive disorder, confusion, headaches, and dizziness. She does not experience numbness in the extremities or changes in bladder control. She has not experienced incidences of memory loss, vertigo, and instability.Obstetrics Comprehensive Patient Assessment.

Psychiatric: she does not have a history of anxiety and depression, mood and thought disorders, as well as confusion. She denies mood swings, suicidal ideation, and substance abuse.

OBJECTIVE

Constitutional

Weight: 155 lbs

Height: 5’ 5’’

BMI: 25.6

Temperature: 99.7 F

Blood pressure: 112/64

Pulse rate: 81

Respiration rate: 19

General

Besides looking well nourished, the patient is healthy and does not appear distressed.

Skin- No lesions or bruises detected on the skin of the patient. She does not have any open cuts, ulcers, rashes, inflammation, redness, or injuries. However, examination of the genital area reveals the presence of small bumps.

HEENT: the head of the patient is free of abnormalities; she does not have scalp tenderness and bald spots; her eyes do not have an abnormal discharge, and the conjunctiva appears pink. The sclera is white and extraocular movements are intact. Corneal light reflex is normal. Her ears have a normal external appearance, and the ear canals are open with no abnormal discharge. The tympanic membrane is clear, and the hearing capacity is intact. The appearance of the patient’s nose is normal; the nostrils are open, with no mucous and septum is midline. The oral mucosa is pink and moist with no missing teeth. No sign of inflammation or lesions in the throat is detected. The tonsils are not inflamed.Obstetrics Comprehensive Patient Assessment.

Cardiovascular: no murmurs, rub or gallops noted; S1 and S2 rate and rhythm normal; no bruits detected; normal pulses detected bilaterally; normal sounds detected through auscultation.

Respiratory: The patient’s respiration is even and unlabored; auscultation reveals clear lung sound. No wheezes and rhonchi detected.

Gastrointestinal: physical examination of the abdomen reveals it is soft and non-tender as well as nondistended; no masses detected, auscultation reveals normal bowel sounds in all quadrants

Breast: the breasts are free of masses, lumps, and abnormal discharge.

Genitourinary/ Gynecological: palpitation does not reveal bladder tenderness or bladder distention. Vaginal mucosa is pink; white vaginal discharge noted; multiple lesions noted on the external genitalia; the warts are broad, soft, and non-keratinized. The cervix is normal; the lymph nodes around the inguinal region are not inflamed.Obstetrics Comprehensive Patient Assessment.

Musculoskeletal: the patient has normal range of motion, and the stability of the joints is normal; the joints are not tender or inflamed.

Neurological: the patient is alert and oriented; her communication ability has not been disrupted; she reveals normal attention and concentration and her sensation to touch is intact.

Psychiatric: the patient’s thoughts are normal and logical, and her judgment is intact. She appears calm and cooperative. Comment by Grammarly: Deleted:l

Immunologic: no bleeding detected; the lymph nodes are not palpable.

Laboratory tests and other diagnostic tests

Urinalysis

The Urine appears yellowish in color

Urine is free from deposits

PH-7.0, SG -1.010, UBG-0.2

Colonoscopy:

Tiny bumps are detected on the skin around the genital area

Pap smear– results of PAP smear are pending

Gonorrhea– results of gonorrhea test are pending

Blood tests:

Complete Blood Count,

Thyroid Stimulating Hormone test,

Antibodies test,

Vitamin D level test

No special tests conducted

ASSESSMENTS

Primary diagnosis: Human papilloma virus

The primary diagnosis for PT is Human papilloma virus. The patient has symptoms that are similar to those of this condition. Some of these symptoms include the presence of small cauliflower bumps on the genital area. The genital warts are detected on the vulva, the cervix as well as in the vagina. In some cases, warts resolve, but in others, they persist for a longer period. In HPV, warts usually appear weeks or even months after a sexual encounter making it hard for the patient to realize she is responsible for transmission of HPV (Rosenblatt & Campos, 2009). The patient is sexually active and has stated that she had a sexual encounter with her longtime friend some weeks ago thus increasing the risk of HPV.Obstetrics Comprehensive Patient Assessment.

Differential Diagnosis:

Genital herpes – Genital herpes is a common sexually transmitted disease. Most of those who have herpes do not know it since it is usually asymptomatic or mild. The common symptoms of this condition are small blisters that eventually break open (Warren, 2009). This condition was ruled out since the patient does not present with flu-like symptoms and swollen lymph nodes.

Chlamydia – There is a possibility of the patient being diagnosed with Chlamydia since she presents with painless soles and mild itching on the genitals. However, this condition was ruled out since the patient does not have a fever, and painful sensation while urinating (Golanty & Edlin, 2012). Also, the patient has not experienced incidences of bleeding between period.Obstetrics Comprehensive Patient Assessment.

Genital sores – The patient can be diagnosed with genital sores since she has red bumps on the genital area. This condition was ruled out for this patient since she does not have swollen glands, severe itching around the genital area, and pain in the legs and buttocks. Also, the patient does not experience painful urination (Germain, 2013).Obstetrics Comprehensive Patient Assessment.

Chancroid – Chancroid is a possible diagnosis for the patient since she has small red bumps on the labia. This condition was ruled out since the patient does not experience pain during urination. The patient does not have swollen lymph nodes and bleeding ulcers, which are common among patients (Carroll, 2012).

PLAN

Further tests:

Colonoscopy and Acetic acid test: colonoscopy involves the examination of the vagina and the cervix. Acetic acid can be applied on the genital area to enhance the degree of visibility of genital warts.

Viral culture: This test involves the use of scrapings of the bumps as well as a swab of cells from the cervix.Obstetrics Comprehensive Patient Assessment.

Treatment

In most cases, genital warts clear on their own; however, when they persist appropriate treatment modalities should be applied. There is a high likelihood of recurrence since viruses have no cure. The treatment of HPV includes a combination of topically and orally administered medications (Woods, 2002).

Salicylic acid: this medication is an over the counter topically administered medication that removes warts over time. This medication should be used cautiously since it may lead to skin irritation (Carroll, 2012).

Imiquimod: Imiquimod is a prescription cream that enhances the body’s immunity over HPV. This medication can generate some side effects including redness of the affected areas and should be applied cautiously (Marr, 2010).Obstetrics Comprehensive Patient Assessment.

Trichloroacetic acid: this medication helps in burning of warts.

Sinecathechins: This cream is usually applied to the genital and anal areas to clear of genital warts. Comment by Grammarly: Deleted:n

Patient education

It is advisable for the patient to limit the number of sexual partners. The patient should also maintain high levels of hygiene, and avoid wearing tight undergarments.

The patient should reduce the application of lotions and creams since excessive use if these medications might lead to severe irritation of the skin.Obstetrics Comprehensive Patient Assessment.