Assignment 2: Comprehensive Well-Woman Exam
Assignment 2: Comprehensive Well-Woman Exam
For a wide variety of medical conditions, early detection of the problem enables timely and more effective treatment. Annual well-woman exams are among the best tools available for health care professionals to identify potential diseases and medical conditions in women.
Advanced nurse practitioners can play an active role in these important visits. This role can include a physical examination as well as collection of details about such factors as nutrition habits, sexual activity, stress, and more. By participating in comprehensive well-woman exams, advanced nurse practitioners can help patients engage in preventative health.
Photo Credit: Teodor Lazarev / Adobe Stock
For this Assignment, you will complete your well-woman exam using a focused note format in which you will gather patient information, relevant diagnostic and treatment information and reflect on health promotion and disease prevention in light of patient factors, such as age, ethnic group, past medical history (PMH), socio-economic status, cultural background, etc. Assignment 2: Comprehensive Well-Woman Exam
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Note: All Focused Notes must be signed, and each page must be initialed by your preceptor. When you submit your Focused Notes, you should include the complete Focused Note as a Word document and pdf/images of each page that is initialed and signed by your preceptor. You must submit your Focused Notes using SAFE ASSIGN.
Note: Electronic signatures are not accepted. If both files are not received by the due date, faculty will deduct points per the Walden Late Policies. Assignment 2: Comprehensive Well-Woman Exam
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, and treatment and management plan, and education strategies and follow-up care.
What additional considerations might you think about if your patient was pregnant or just delivered?
Use the “Guidelines for Comprehensive History and Physical SOAP Note” document found in this week’s Learning Resources to guide you as you complete this Assignment.
Assignment:
Write an 8- to 10-page Comprehensive Well-Woman Exam 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
Provide evidence-based guidelines to support treatment plan. Note: Use your Learning Resources and evidence from scholarly sources from your personal search to support your treatment plan of care. Assignment 2: Comprehensive Well-Woman Exam
Reflection
Reflect on some additional factors for your patient:
What are the implications if your patient was pregnant or just delivered?
What are implications if you have observed or know of some domestic violence? Would this change your plan of care? If so, how?
Use your Learning Resources and evidence from scholarly sources from your personal search to support your reflection.
Reminder: The College of Nursing requires that all papers submitted include a title page, introduction, summary, and references. The Sample Paper provided at the Walden Writing Center provides an example of those required elements (available at http://writingcenter.waldenu.edu/57.htm).
Note: Your Comprehensive Well-Woman Exam Assignment must be signed by Day 7 of Week 10.
By Day 7
Submit your Comprehensive Well-Woman Exam Assignment by Day 7. (Note: You will submit two files, your Comprehensive Well-Woman Exam Assignment, and a Word document of pdf/images of each page that is initialed and signed by your preceptor by Day 7 of Week 10.)Assignment 2: Comprehensive Well-Woman Exam
Submission and Grading Information
To submit your completed Assignment for review and grading, do the following:
Please save your Assignment using the naming convention “WK10Assgn3+last name+first initial.(extension)” as the name.
Click the Week 10 Assignment 3 Rubric to review the Grading Criteria for the Assignment.
Click the Week 10 Assignment 3 link. You will also be able to “View Rubric” for grading criteria from this area.
Next, from the Attach File area, click on the Browse My Computer button. Find the document you saved as “WK10Assgn3+last name+first initial.(extension)” and click Open.
If applicable: From the Plagiarism Tools area, click the checkbox for I agree to submit my paper(s) to the Global Reference Database.
Click on the Submit button to complete your submission.
Rubric Detail
Select Grid View or List View to change the rubric’s layout.
Content
Name: PRAC_6552_Week10_Assignment3_Rubric
Assignment 2: Comprehensive Well-Woman Exam
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List View
Excellent Good Fair Poor
Write an 8- to 10-page Comprehensive Well-Woman Exam 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
• Provide evidence-based guidelines to support treatment plan.
Points Range: 40.5 (40.5%) – 45 (45%)
All required points are addressed, with results that are presented fully and clearly
Provides 5 current and credible scholarly sources to support the treatment plan of care. Assignment 2: Comprehensive Well-Woman Exam
Points Range: 36 (36%) – 40 (40%)
At least 8 points are addressed with results that are presented clearly.
Provides at least 4 current and credible scholarly sources to support the treatment plan of care.
Points Range: 31.5 (31.5%) – 35 (35%)
No fewer than 7 points are addressed. One or more results presented in a manner that is vague or incomplete.
Provides at least 3 current and credible scholarly sources to support the treatment plan of care. Assignment 2: Comprehensive Well-Woman Exam
Points Range: 0 (0%) – 34 (34%)
Fewer than 7 points are addressed. One or more results are presented in a manner that is vague, incomplete, or inacurrate.
Provides at least 2 current and credible scholarly sources to support the treatment plan of care.
Reflect on the following:
Reflect on some additional factors for your patient:
• What are the implications if your patient was pregnant or just delivered?
• What are implications if you have observed or know of some domestic violence? Would this change your plan of care? If so, how?
Points Range: 36 (36%) – 40 (40%)
Reflection is clearly presented, with implications that are well-formed, clear, and fully expressed.
Provides at least 3 current and credible scholarly sources to support reflection.
Points Range: 32 (32%) – 39 (39%)
Reflection is clearly presented, with implications that are clearly expressed.
Provides at least 3 current and credible scholarly sources to support reflection.
Points Range: 28 (28%) – 31 (31%)
Reflection is presented in manner that is vague or unclear. Implications are not fully or clearly expressed.
Provides at least 2 current and credible scholarly source to support reflection. Assignment 2: Comprehensive Well-Woman Exam
Points Range: 0 (0%) – 30 (30%)
Reflection is presented in manner that is vague or unclear. Implications are unclear, or one or both implications not expressed.
Provides at least 1 current and credible scholarly source to support reflection.
Written 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 is provided which delineates all required criteria.
Points Range: 5 (5%) – 5 (5%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity.
A clear and comprehensive purpose statement, introduction, and conclusion is provided which delineates all required criteria.
Points Range: 4 (4%) – 4 (4%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity 80% of the time.
Purpose, introduction, and conclusion of the assignment is stated, yet is brief and not descriptive.
Points Range: 3.5 (3.5%) – 3.5 (3.5%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity 60–79% of the time.
Purpose, introduction, and conclusion of the assignment is vague or off topic. Assignment 2: Comprehensive Well-Woman Exam
Points Range: 0 (0%) – 3 (3%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity <60% of the time.
No purpose statement, introduction, or conclusion was provided.
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Written Expression and Formatting – English writing standards:
Correct grammar, mechanics, and proper punctuation
Points Range: 5 (5%) – 5 (5%)
Uses correct grammar, spelling, and punctuation with no errors.
Points Range: 4 (4%) – 4 (4%)
Contains a few (1 or 2) grammar, spelling, and punctuation errors.
Points Range: 3.5 (3.5%) – 3.5 (3.5%)
Contains several (3 or 4) grammar, spelling, and punctuation errors.
Points Range: 0 (0%) – 3 (3%)
Contains many (≥ 5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding.
Written Expression and Formatting – The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, parenthetical/in-text citations, and reference list.
Points Range: 5 (5%) – 5 (5%)
Uses correct APA format with no errors.
Points Range: 4 (4%) – 4 (4%)
Contains a few (1 or 2) APA format errors.
Points Range: 3.5 (3.5%) – 3.5 (3.5%)
Contains several (3 or 4) APA format errors.
Points Range: 0 (0%) – 3 (3%)
Contains many (≥5) APA format errors.
Total Points: 100
Name: PRAC_6552_Week10_Assignment3_Rubric
NURS 6552 PRAC Advanced Nurse Practice in Reproductive Health
Assignment: Comprehensive Well Woman Examination
Walden University
11/03/2021
Week 10 Assignment: Well Woman Examination
Patient Information:
Name: M.A, Age: 68years,Sex: Female,Race: African American
Subjective data
CC (chief complaint): “I have some irregular vaginal bleeding”
HPI:Ms. Arthuris a 68-year-old African American post-menopausal woman that presents with irregular vaginal bleeding, twice in last 3 months. She describes it as a “heavy menstrual period that lasted for 2 days, each episode”. She denied vaginal irritation but endorsed vaginal dryness.Assignment 2: Comprehensive Well-Woman Exam
Her last menstrual period was at 30 years ago. She lives at home with her husband, in a single-story building with working smoke detectors. She smokes a half a pack of cigarettes per day, since age 20, quit smoking 5 years ago. Denies alcohol or illicit drug use. She has a family history ofHypertension, Prostate Cancer, and hyperlipidemia.
Current Medications: Aspirin 81mg 1 tablet orally daily
: Lisinopril 20mg 1 tablet orally daily
: Rosuvastatin 20mg 1 tablet orally daily
: Januvia 100mg 1 tablet orally daily
: Triamterene-HTCZ 37.5-25mg 1 tablet orally daily
: Allopurinol 100mg 1 capsule orally daily
Allergies: No known drug allergy. No allergy to latex, or animals.
PMHx: Hypertension, Type 2 diabetes Mellitus, Hyperlipidemia, Uterine prolapse, and Gouty arthritis. She had Angioplasty June 2003. I hospitalizations for hypertension management- 2018. Influenza immunization received September 2021.COVID vaccination: completed 2 doses (Pfizer). Hepatitis vaccine: Up to date. Pneumonia vaccine: May 2019.
Soc Hx: Ms. Arthur is a married Mother of 3 living children, 40, 38, and 36. Denied current tobacco and alcohol use. Reports history smoking cigarettes, quit 2016. She enjoys walk around the block with her husband. Volunteers atthe local women’s shelter. She is an active choir member of her local church—1st Baptist church. Uses seat belt and avoids handheld phone call while driving. She maintains a healthy weight, with diet and exercise.
Fam Hx: Both parents are deceased, father had hypertensive and prostate cancer. Mother had type 2 diabetes, uterine, breast cancer, and arthritis. Paternal Grandfather had hypertension and died at age 90. Paternal Grandmother had congestive heart disease and died of stroke at age 83. Maternal grandfather had hypertension, died at age 86, maternal grandmother is deceased with no known medical condition. Three biologic children are alive and healthy. Five grandchildren alive and well. No report of family genetic disorders or mental illnesses.
ROS:
GENERAL: No weight loss, fever, chills, denies lack of sleep.
HEENT: Eyes: Wears eyeglasses, denies visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat: Denies hearing loss, nasalcongestion, or sore throat.
SKIN: No rash or itching.
CARDIOVASCULAR: No chest pain, chest pressure or chest discomfort. No palpitations, edema non heart murmurs.
RESPIRATORY: Denies nasal congestion, denies shortness of breath, cough, or sputum. Chest wall clear on all lobes.
GASTROINTESTINAL: No anorexia, nausea, vomiting, constipation, or diarrhea. No report of abdominal pain or blood in stool.
GENITOURINARY: Denies dysuria, dribbling, urgency, or blood in urine. Reports heavy menstrual bleeding. Use of more than 3 pads a day. Uses pessary for uterine prolapse. Tubal ligation 1985. Denies post coital bleeding. Mammogram: Feb; 2020. Last PAP smear : 10/13/2021 (Negative).
NEUROLOGICAL: No report of headaches. Denies dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.
MUSCULOSKELETAL: Denies muscle discomfort, back pain. Reports occasional gouty joint pain, or stiffness from gouty arthritis.
HEMATOLOGIC: Denies anemia, bleeding, or bruising. No history of blood transfusion.
LYMPHATICS: No report of enlarged nodes. No history of splenectomy.
PSYCHIATRIC: No history of depression or anxiety.
ENDOCRINOLOGIC: History of Type 2 diabetes. Deniesunusual sweating, cold or heat intolerance. Denies excess thirst or urination.Assignment 2: Comprehensive Well-Woman Exam
ALLERGIES: Denies history of asthma, hives, or eczema. Report of seasonal allergy.
O.
Vitals: HT: 5’5, WT: 178 lbs.BMI: 29.6, Temp: 98.4, HT: 84, Resp: 14, BP:124/82, O2: 99%
Physical exam: Ms. Arthur is a 68 yr. old African Americanfemale presenting to the clinic for annual well woman examination, and complaint of irregular menstrual bleeding x 2 times in 3 months. Patient is alert and oriented x4, appropriately dressed and groomed. Answers questions without hesitancy and makes good eye contact.
HEENT: WNL
Neck: WNL
Lungs: clear to auscultation in all lung fields
Breast: no masses noted. No discharge from nipples.
GASTROINTESTINAL: normoactive BS. Mild bloating
VVBSU: bloody discharge
Cervix: bloody discharge noted
Uterus: +tenderness
Adnexa: + tenderness
Diagnostics:
– Complete blood count: To assesses for anemia, for report of heavy menstrual bleeding.
– Complete basic panel (BMP): To assess electrolytes, kidneys, and liver function.
– PT/INR: To assess for clotting factors.
– Electrocardiogram: To assess state of the heart muscles, for patient with hypertension
– Uterine and pelvic Ultrasound: Ultrasonography can be helpful in measuring endometrial thickness and in detecting structural abnormalities of the uterus and endometrium, such as polyps, myomas, and fibroids (Holland et al., 2016).Assignment 2: Comprehensive Well-Woman Exam
– Transvaginal ultrasound: Is the first line diagnostic test in postmenopausal women with chief complaint of uterine bleeding (Faizan&Muppidi, 2021).
– Endometrial biopsy: Abnormal findings by TVU, unsuspected abnormalities on EUA and/or suspicious, atypical, or malignant endometrial sampling may require further scanning and tissue diagnosis (Mahdy, Casey, &Crotzer, 2021).
A.
Differential Diagnoses:
White coat hypertension:All hypertensive patients with diabetes should have home blood pressure monitored to identify white-coat hypertension, as majority of these patient’s normal blood pressure are said to be lower at home than at the physician’s office. Patients are at intermediate cardiovascular risk between normotensives and sustained hypertensives. The diagnosis needs confirmation with repeated office and out-of-office BP measurements. If their total cardiovascular risk is low and there is no hypertension-mediated organ damage (HMOD), drug treatment may not be prescribed. However, they should be followed with lifestyle modification, as they may develop sustained hypertension requiring drug treatment (De Boer, Bangalore, Benetos, Davis, Michos, Muntner, Rossing, Zoungas, &Bakris, 2017)
Uterine cancer: The most likely diagnosis for Ms. Arthuris uterine prolapse Since she was a smoker, and is obese, which places her at a higher risk for uterine cancer. Her signs and symptoms of irregularvaginal bleeding, uterine tenderness, and dryness points to that diagnosis. Endometrial cancer is the most common gynecologic malignancy, and the 4th most common cancer in women in the United States, after breast, lung, and colorectal cancer (Schuiling, &Likis, 2022).Assignment 2: Comprehensive Well-Woman Exam
Uterine polyps: Uterine polyps are focal endometrial outgrowths that can occur anywhere within the uterine cavity. They contain a variable number of glands, stroma and blood vessels, the relative amounts of which influence their visual appearance at hysteroscopy (Clark & Stevenson, 2017). Most uterine polyps are diagnosed at imaging by transvaginal pelvic ultrasound (TVUS), or hysteroscopy and confirmation is provided by histological examination of the removed specimen (Clark & Stevenson, 2017).
Endometrial hyperplasia: Endometrial hyperplasia (EH) is a common gynecological endocrine disease, which mainly manifests as irregular vaginal bleeding, infertility, and even malignant transformation. Endometrial dysplasia has certain tendency to become cancerous, and it is recognized as a precancerous lesion of EC with incidence of 23.15–29.08%. Therefore, early detection and intervention of EH is of great significance to improve the prognosis of patients (Zhao, Hu, Zhao, Chen, Fang & Ding, 2021).
Assignment 2: Comprehensive Well-Woman Exam
Treatment and Management
Postmenopausal women are questioned about presence of vaginal bleed at every well woman visit, this practicepromotes awareness among women and health care providers of the need for timely evaluation of abnormal vaginal bleeding, patients need education on normal and abnormal vaginal bleeding, while involving them in their careto increase the chance that uterinecancer is detected early and treated promptly and appropriately(Henley, Miller, Dowling, Benard& Richardson, 2018.,Schuiling, &Likis, 2022). Management of hypertension with goal of keeping BP less than 130/80mmHg. Patient might need to be started on statin to prevent organ damage (Scordo, 2017).
Health education:
Patient education on healthy lifestyle choices have been shown to prevent and reduce cardiovascular risk (Scordo, 2017).
Weight reduction through the incorporation of some form of physical activity daily (Schuiling, &Likis, 2022).
Diet modification to include food rich in iron and calcium. Patient to include healthy diet like Mrs. Dash diet, limit sodium, and avoid fried foods.Assignment 2: Comprehensive Well-Woman Exam
Summary
Abnormal vaginal bleeding, including bleeding between periods or after sex or any unexpected bleeding after menopause, is most common in female over the 40, history of PCOS, are overweight and a family history of cancer (Schuiling, &Likis, 2022).Cardiovascular risk should be assessed in all hypertensive patients, especially for high-risk patients like Ms. Arthur with type 2 diabetes, history of Smoking and family history of heart disease. Annual medical checkup is advised, especially for persons with risk factors like Ms. Arthur. All high-risk women should adopt a healthy lifestyle that includes exercise, eating well, and aiming for ideal body weight, to lessen risk for cardiovascular diseases and mortality reduction.
Reflection
A well-woman visit provides an excellent opportunity to counsel patients about maintaining a healthy lifestyle and minimizing health risks.Certain risk factors and behaviors have a profound negative effect on the health of women and should be addressed during a well-woman visit. Smoking, poor diet, and lack of physical activity are associated with cardiovascular disease, type 2 diabetes, and multiple types of cancer, among other conditions that cause significant morbidity and are the leading causes of mortality in the United States (The American College of Obstetricians and gynecologists. org, 2018).There are significant long-term cardiovascular risks for women with chronic hypertension and those who have had gestational hypertension or preeclampsia or other commodities like type 2 diabetes.
Follow up appointment:
Patient to return to clinic in 1 week for review of labs and monitor blood pressure
To keep of log of blood pressure reading, to compare with office records.
Follow up in 6 months for repeat PAP smear
Assignment 2: Comprehensive Well-Woman Exam
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References
Clark, T.J. & Stevenson, H. (2017). Endometrial polyps and abnormal uterine bleeding (AUB-P): What is the relationship, how are they diagnosed and how are they treated? Https://www-sciencedirect-com.ezp.waldenulibrary.org/science/article/pii/
De Boer, I., Bangalore, S., Benetos, A., Davis, A.M., Michos, E.D., Muntner, P., Rossing, P., Zoungas, S. &Bakris, G. (2017). Diabetes and hypertension: A position statement by the American Diabetes Association. Https://care.diabetesjournals.org/content/40/9/1273
Faizan, U., &Muppidi, V. (2021). Uterine Cancer. Https://www.statpearls.com/articlelibrary/viewarticle/30892.
Henley, S.J., Miller, J.W., Dowling, N.F., Benard, V.B. & Richardson, L.C. (2018). Uterine cancer incidence and mortality-United States, 1999-2016. Https://eds-p-ebscohost-com.ezp.waldenulibrary.org/eds/detail/detail
Holland, A., Hodges, A., Catron, K., Bevis, K., Berman, N., &Meneses, K. (2016). Endometrial cancer: Using evidence to impact practice and policy. The journal for Nurse practitioners.Https://www.npjournal.org/article/S1555-4155/
Mahdy, H., Casey, M., &Crotzer, D. (2021). Endometrial cancer.Https://www.statpearls.com/articlelibrary/viewarticle/21102
Schuiling, K.D., &Likis, F.E. (2022). Gynecologic health care: With an introduction to prenatal and postpartum care. 4TH ed. Jones & Bartlett learning.
Scordo, K. A. (2017). Hypertension management options:2017 guidelines. Https://oce-ovid-com.ezp.waldenulibrary.org/article/00006205
Seagle, B-L.L., Sobecki-Rausch, J., Strohl, A.E., Shilpi, A., Grace, A., &Shahabi, S. (2017). Prognosis and treatment of uterine leiomyosarcoma: A National cancer Database study.https://www-sciencedirect-com.ezp.waldenulibrary.org/science/article/pii
The American College of Obstetricians and Gynecologists.org (2018). Well-Woman visits. Https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/
Zhao, J., Hu, Y., Zhao, Y., Chen, D., Fang, T., & Ding, M. (2021). Risk factors of endometrial cancer in patients with endometrial hyperplasia: implications for clinical treatments.https://eds-p-ebscohost-com.ezp.waldenulibrary.org/eds/detail/
Assignment 2: Comprehensive Well-Woman Exam
