NURS 6512 Week 10 Assignment: GENITALIA ASSESSMENT

NURS 6512 Week 10 Assignment: GENITALIA ASSESSMENT

NURS 6512 Week 10 Assignment: GENITALIA ASSESSMENT

GENITALIA ASSESSMENT

Subjective:

CC: dysuria and urinary frequency
HPI: RG is a 30 year old female with increase urinary frequency and dysuria that began 3 days ago. Pain is intermittent and described a burning only in urination, but c/o flank pain since last night. Reports intermittent chills and fever. Used Tylenol for pain with no relief. She rates her pain 6/10 on urination. Reports a similar episode 3 years ago.

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PMH: UTI 3 years ago
PSHx: Hysterectomy at 25 years
Medication: Tylenol 1000 mg PO every 6 hours for pain
FHx: Mother breast cancer ( alive) Father hypertension (alive)
Social: Single, no tobacco , works as a bartender, positive for ETOH
Allergies: PCN and Sulfa
LMP: N/A
Review of Symptoms:

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

VS: Temp 100.9; BP: 136/80; RR 18; HT 6’.0”; WT 135lbs
Abdominal: Bowel sounds present x 4. Palpation pain in both lower quadrants. CVA tenderness
Diagnostics: Urine specimen collected, STD testing
Assessment:

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

guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.

Chapter 17, “Breasts and Axillae”

This chapter focuses on examining the breasts and axillae. The authors describe the examination procedures and the anatomy and physiology of breasts.

Chapter 19, “Female Genitalia”

In this chapter, the authors explain how to conduct an examination of female genitalia. The chapter also describes the form and function of female genitalia.

Chapter 20, “Male Genitalia”

The authors explain the biology of the penis, testicles, epididymides, scrotum, prostate gland, and seminal vesicles. Additionally, the chapter explains how to perform an exam of these areas.

Chapter 21, “Anus, Rectum, and Prostate”

This chapter focuses on performing an exam of the anus, rectum, and prostate. The authors also explain the anatomy and physiology of the anus, rectum, and prostate.
Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Advanced health assessment and clinical diagnosis in primary care (6th ed.). St. Louis, MO: Elsevier Mosby.

Credit Line: Advanced Health Assessment and Clinical Diagnosis in Primary Care, 6th Edition by Dains, J.E., Baumann, L. C., & Scheibel, P. Copyright 2019 by Mosby. Reprinted by permission of Mosby via the Copyright Clearance Center.

Chapter 5, “Amenorrhea”

A Sample Of This Assignment Written By One Of Our Top-rated Writers

Assignment Week 10

Subjective and objective data guide healthcare providers in making an appropriate diagnosis. The presented scenario is about RG, a 30yo female with dysuria and increase urinary frequency. The client reports that the symptoms started three days ago. She reveals that burning only occurs with urination and pain is intermittent. The client reports a similar incident 3 years ago when she was diagnosed with UTI. During diagnostics, urine specimen was collected and STD testing was performed. However, additional objective and subjective data are required in making an appropriate diagnosis and treatment.

Additional Subjective Data

In collecting additional subjective data, the healthcare provider should ask the client if the symptoms have been worsening gradually since the onset. Secondly, the client should ask the client if she is sexually active. If yes, the clinician should ask the client if she uses protection during the intercourse and if her partner has complained of similar symptoms. Lastly, the healthcare provider should ask the patient if the previous UTI was effectively treated using antibiotics and whether the reported symptoms remitted completely.

Additional Objective Data

Additional objective data will guide healthcare providers in making appropriate diagnoses and developing an effective treatment plan. The healthcare provider should check other clinical manifestations such as the presence of vaginal discharge, rashes on the vulva and opening of the vagina, blood in the urine, or swellings or sores in the genitals. Additionally, the healthcare provider should conduct a urine culture to determine the specific bacteria responsible for the presented symptoms. The results would guide healthcare providers in providing the best treatment to the client.

How do Subjective and Objective Data Support the Assessment?

The client’s assessment is urinary tract infection (UTI), which is mainly characterized by a persistent and strong urge to urinate, a burning sensation with urination, cloudy appearing urine, passing small amounts of urine frequently, urine that appears bright pink or red, strong-smelling urine, and signs of blood in the urine (Gupta et al., 2017). The client reports dysuria and increase urinary frequency. Additionally, UTI is characterized by the presence of bacteria in the urinary tract system. The urine specimen collected from the client indicates the presence of bacteria. Therefore, subjective and objective data support the client’s assessment of UTI.

Appropriate Diagnostics

            Analysis of urine samples can be used in diagnosing UTIs. The urine sample is examined under a microscope. The presence of white blood cells or bacteria in the urine sample are signs of an infection (Cheung et al., 2017). Hence a person is diagnosed with UTI. Additionally, a urine culture can be performed during UTI diagnosis (Pérez et al., 2019). The results might indicate the presence of yeast or bacteria that might be causing the UTI.

Opinion regarding the current Diagnosis

I support UTI as the client’s current diagnosis. This condition is characterized by a persistent and strong urge to urinate, a burning sensation with urination, cloudy appearing urine, passing small amounts of urine frequently, urine that appears bright pink or red, strong-smelling urine, and signs of blood in the urine (Ahmed, 2018). The client reports dysuria and increased urinary frequency, qualifying for this diagnosis. Additionally, the presence of bacteria in the urine indicates the client has UTI. However, a differential diagnosis should be conducted to rule out potential diagnoses, including perinephric abscess, renal tuberculosis, urethral syndrome, and fungal infections of the urinary tract system.

Overall, the client has been diagnosed with UTI. However, additional subjective and objective data are required to confirm the client’s current diagnosis. Additionally, a differential diagnosis is needed to rule out other conditions with overlapping symptoms.

References

Ahmed, I. I. M. (2018). Determination of Invitro Antibacterial Activity of Ginger Extract on Bacteria Isolated from Diabetic Patient with Urinary Tract Infections in Shendi Locality (Doctoral dissertation, Leila Mohammed Ahmed Abdelgadeir).

Cheung, F., Loeb, C. A., Croglio, M. P., Waltzer, W. C., & Weissbart, S. J. (2017). Bacteria on urine microscopy is not associated with systemic infection in patients with obstructing urolithiasis. Journal of Endourology, 31(9), 942-945.

Gupta, K., Grigoryan, L., & Trautner, B. (2017). Urinary tract infection. Annals of internal medicine, 167(7), ITC49-ITC64.

Pérez, R. P., Ortega, M. J. C., Álvarez, J. A., Baquero-Artigao, F., Rico, J. C. S., Zúñiga, R. V., … & de Liria, C. R. G. (2019). Recommendations on the diagnosis and treatment of urinary tract infection. Anales de Pediatría (English Edition), 90(6), 400-e1.