Nursing Assessment Paper

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  • 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 five possible conditions that may be considered in a differential diagnosis for the patient. Nursing Assessment Paper

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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.

 

GENITALIA ASSESSMENT (Review the requirements in this week’s course resources.  You can write this assignment in narrative format.

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.
  • 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. Nursing Assessment Paper

Assessment:

  • UTI
  • STD