Assignment: NURS 6512 Week 10 Assessing the Genitalia and Rectum

Patients are frequently uncomfortable discussing with healthcare professional’s issues that involve the genitalia and rectum; however, gathering an adequate history and properly conducting a physical exam are vital. Examining case studies of genital and rectal abnormalities can help prepare advanced practice nurses to accurately assess patients with problems in these areas.

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In this Lab Assignment, you will analyze an Episodic note case study that describes abnormal findings in patients seen in a clinical setting. You will consider what history should be collected from the patients, as well as which physical exams and diagnostic tests should be conducted. You will also formulate a differential diagnosis with several possible conditions.

Review the Episodic note case study your instructor provides you for this week’s Assignment. Please see the “Course Announcements” section of the classroom for your Episodic note case study.
Based on the Episodic note case study:
- Review this week’s Learning Resources, and consider the insights they provide about the case study. Refer to Chapter 3 of the Sullivan resource to guide you as you complete your Lab Assignment.
- Search the Walden library or the Internet for evidence-based resources to support your answers to the questions provided.
- Consider what history would be necessary to collect from the patient in the case study.
- Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis?
- Identify at least fivepossible conditions that may be considered in a differential diagnosis for the patient.

YOU will need this case study to complete the Lab Assignment for this week.

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SEE EPISODIC SOAP NOTE BELOW

Episodic note case study: Genitalia Assessment listed below.

Genitourinary Assessment

CC: Increased frequency and pain with urination

HPI:

T.S. is a 32-year-old woman who reports that for the past two days, she has dysuria, frequency, and urgency. Has not tried anything to help with the discomfort. Has had this symptom years ago. She is sexually active and has a new partner for the past 3 months.

Medical History:

None

Surgical History:

Tonsillectomy in 2001
Appendectomy in 2020

Review of Systems:

General: Denies weight change, positive for sleeping difficulty because e the flank pain. Feels warm.
Abdominal: Denies nausea and vomiting. No appetite

Objective

VSS T = 37.3°C, P = 102/min, RR = 16/min, and BP = 116/74 mm Hg.

Pelvic Exam:

mild tenderness to palpation in the suprapubic area
bimanual pelvic examination reveals a normal-sized uterus and adnexae
no adnexal tenderness.
No vaginal discharge is noted.
The cervix appears normal.
Diagnostics: Urinalysis, STI testing, Papsmear

Assessment:

UTI
STI

PLAN: This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.

***Please DO NOT Recopy this SOAP Note to your Assignment for Submission!!!

THE LAB ASSIGNMENT

Using evidence-based resources from your search, answer the following questions and support your answers using current evidence from the literature.

Analyze the subjective portion of the note. List additional information that should be included in the documentation.
Analyze the objective portion of the note. List additional information that should be included in the documentation.
Is the assessment supported by the subjective and objective information? Why or why not?
Would diagnostics be appropriate for this case, and how would the results be used to make a diagnosis?
Would you reject/accept the current diagnosis? Why or why not? Identify three possible conditions that may be considered as a differential diagnosis for this patient. Explain your reasoning using at least three different references from current evidence-based literature.
THIS IS THE SAME AS WHAT YOU DID FOR WEEK 6.
This should be a paper with subheadings, please use subheadings below. This makes your papers a lot easier to read and ensures you are answering all the questions on the Rubric. Be sure to answer all information to receive maximum points.
Subheadings

– Subjective Portion

– Objective Portion

– Assessment Supported

– Diagnostic Tests

– Rejection or Acceptance

– Possible Conditions

This should be written as a narrative/paragraphs only!

DO NOT rewrite a SOAP note!!!

Tell me what’s wrong with the Episodic SOAP Note, by responding to the statements/questions above.

This is the same as Week 6 (GI SOAP note). Look at the comments and lets all make a great effort to answer each question in PARAGRAPH form. Please DO NOT do this in SOAP note format.

NURS_6512_Week_10_Assignment1_Rubric

NURS_6512_Week_10_Assignment1_Rubric

Criteria

Ratings

Pts

This criterion is linked to a Learning OutcomeWith regard to the SOAP note case study provided and using evidence-based resources from your search, answer the following questions and support your answers using current evidence from the literature:· Analyze the subjective portion of the note. List additional information that should be included in the documentation.

12 to >9.0 pts

Excellent

The response clearly, accurately, and thoroughly analyzes the subjective portion of the SOAP note and lists detailed additional information to be included in the documentation.

9 to >6.0 pts

Good

The response accurately analyzes the subjective portion of the SOAP note and lists additional information to be included in the documentation.

6 to >3.0 pts

Fair

The response vaguely analyzes the subjective portion of the SOAP note and vaguely and/or inaccurately lists additional information to be included in the documentation.

3 to >0 pts

Poor

The response inaccurately analyzes the subjective portion of the SOAP note, with inaccurate and/or missing additional information included in the documentation.

12 pts

This criterion is linked to a Learning Outcome· Analyze the objective portion of the note. List additional information that should be included in the documentation.

12 to >9.0 pts

Excellent

The response clearly, accurately, and thoroughly analyzes the objective portion of the SOAP note and lists detailed additional information to be included in the documentation.

9 to >6.0 pts

Good

The response accurately analyzes the objective portion of the SOAP note and lists additional information to be included in the documentation.

6 to >3.0 pts

Fair

The response vaguely analyzes the objective portion of the SOAP note and vaguely and/or inaccurately lists additional information to be included in the documentation.

3 to >0 pts

Poor

The response inaccurately analyzes the objective portion of the SOAP note, with inaccurate and/or missing additional information included in the documentation.

12 pts

This criterion is linked to a Learning Outcome· Is the assessment supported by the subjective and objective information? Why or why not?

16 to >13.0 pts

Excellent

The response clearly and accurately identifies whether or not the assessment is supported by the subjective and/or objective information, with a thorough and detailed explanation.

13 to >10.0 pts

Good

The response accurately identifies whether or not the assessment is supported by the subjective and/or objective information, with a clear explanation.

10 to >7.0 pts

Fair

The response vaguely identifies whether or not the assessment is supported by the subjective and/or objective information, with a vague explanation.

7 to >0 pts

Poor

The response inaccurately identifies whether or not the assessment is supported by the subjective and/or objective information, with an inaccurate or missing explanation.

16 pts

This criterion is linked to a Learning Outcome· What diagnostic tests would be appropriate for this case, and how would the results be used to make a diagnosis?

20 to >17.0 pts

Excellent

The response thoroughly and accurately describes appropriate diagnostic tests for the case and explains clearly, thoroughly, and accurately how the test results would be used to make a diagnosis.

17 to >14.0 pts

Good

The response accurately describes appropriate diagnostic tests for the case and explains how the test results would be used to make a diagnosis.

14 to >11.0 pts

Fair

The response vaguely and/or with some inaccuracy describes appropriate diagnostic tests for the case and vaguely and/or with some inaccuracy explains how the test results would be used to make a diagnosis.

11 to >0 pts

Poor

The response inaccurately describes appropriate diagnostic tests for the case, with an inaccurate or missing explanation of how the test results would be used to make a diagnosis.

20 pts

This criterion is linked to a Learning Outcome· Would you reject or accept the current diagnosis? Why or why not?· Identify three possible conditions that may be considered as a differenial diagnosis for this patient. Explain your reasoning using at least three different references from current evidence-based literature.

25 to >22.0 pts

Excellent

The response states clearly whether to accept or reject the current diagnosis, with a thorough, accurate, and detailed explanation of sound reasoning. The response clearly, thoroughly, and accurately identifies three conditions as a differential diagnosis, with reasoning that is explained clearly, accurately, and thoroughly using three or more different references from current evidence-based literature.

22 to >19.0 pts

Good

The response states whether to accept or reject the current diagnosis, with an accurate explanation of sound reasoning. The response accurately identifies three conditions as a differential diagnosis, with reasoning that is explained using three different references from current evidence-based literature.

19 to >16.0 pts

Fair

The response states whether to accept or reject the current diagnosis, with a vague explanation of the reasoning. The response identifies two to three conditions as a differential diagnosis, with reasoning that is explained vaguely and/or inaccurately using three or fewer references from current evidence-based literature.

16 to >0 pts

Poor

The response inaccurately states or is missing a statement of whether to accept or reject the current diagnosis, with an explanation that is inaccurate and/or missing. The response identifies three or fewer conditions as a differential diagnosis, with reasoning that is missing or explained inaccurately using two or fewer references from current evidence-based literature.

25 pts

This criterion is linked to a Learning OutcomeWritten Expression and Formatting – Paragraph Development and Organization: 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 to >4.0 pts

Excellent

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 to >3.0 pts

Good

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 to >2.0 pts

Fair

Paragraphs and sentences follow writing standards for flow, continuity, and clarity 60%–79% of the time. Purpose, introduction, and conclusion of the assignment are vague or off topic.

2 to >0 pts

Poor

Paragraphs and sentences follow writing standards for flow, continuity, and clarity < 60% of the time. No purpose statement, introduction, or conclusion were provided.

5 pts

This criterion is linked to a Learning OutcomeWritten Expression and Formatting – English writing standards: Correct grammar, mechanics, and proper punctuation

5 to >4.0 pts

Excellent

Uses correct grammar, spelling, and punctuation with no errors.

4 to >3.0 pts

Good

Contains a few (1 or 2) grammar, spelling, and punctuation errors.

3 to >2.0 pts

Fair

Contains several (3 or 4) grammar, spelling, and punctuation errors.

2 to >0 pts

Poor

Contains many (≥ 5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding.

5 pts

This criterion is linked to a Learning OutcomeWritten 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 to >4.0 pts

Excellent

Uses correct APA format with no errors.

4 to >3.0 pts

Good

Contains a few (1 or 2) APA format errors.

3 to >2.0 pts

Fair

Contains several (3 or 4) APA format errors.

2 to >0 pts

Poor

Contains many (≥ 5) APA format errors.

5 pts

Total Points: 100

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Assignment: NURS 6512 Week 10 Assessing the Genitalia and Rectum

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Assignment: NURS 6512 Week 10 Assessing the Genitalia and Rectum