Assignment: Common Health Conditions with Implications for Women Paper

Assignment: Common Health Conditions with Implications for Women Paper

Assignment: Common Health Conditions with Implications for Women Paper

Assignment: Common Health Conditions with Implications for Women Sample

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Episodic/Focused SOAP Note Template

Patient Information:

Initials: M.A; Age: 48 years, Sex: Female, Race: Native American

S.

CC (chief complaint): “Urinary leakage.”

HPI:

M.A. is a 48-year-old, Native American who presents to the clinic with a complaint of urinary leakage. She states that the urinary leakage has increasingly worsened over the past two years. She is forced to wear a pad all the time. She reports that the urinary leakage interferes with her work as she keeps going to the bathroom all the time.

Current Medications: None.

Allergies: None

PMHx: Immunization is current. No chronic illnesses.

Soc& Substance Hx: M.A. is an auditor. She is married and has two children 24 and 19 years. Her hobbies are baking and traveling. She reports taking 2-3 glasses of wine on weekends but denies smoking or using illicit substances.

Fam Hx: No family history of chronic illnesses.

Surgical Hx: Surgical history is remarkable for wisdom teeth extraction and bilateral tubal ligation.

Mental Hx: None.

Violence Hx: No history of domestic violence.

Reproductive Hx: LMP-2 weeks ago. No history of menstrual disorders. Para 2+0. Currently on IUD. She is homosexual.

ROS:

GENERAL: Denies weight loss, fever, chills, weakness, or fatigue.

HEENT: Eyes: Denies visual changes, blurred/double vision, hearing loss, sneezing, congestion, runny nose, or sore throat.

SKIN: Denies rash or itching.

CARDIOVASCULAR: Denies chest pain, palpitations, or edema.

RESPIRATORY: Denies shortness of breath, cough, or sputum.

GASTROINTESTINAL: Denies anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood.

NEUROLOGICAL: Positive for lack of bladder control. Denies headache, dizziness, syncope, paralysis, or tingling in the extremities.

MUSCULOSKELETAL: Denies muscle pain, back pain, joint pain, or stiffness.

HEMATOLOGIC: Denies anemia, bleeding, or bruising.

LYMPHATICS: Negative for enlarged nodes.

PSYCHIATRIC: Denies a history of depression or anxiety.

ENDOCRINOLOGIC: Denies excessive sweating, cold/heat intolerance, polyuria, or polydipsia.

GENITOURINARY/REPRODUCTIVE: Reports urinary leakage. Denies dysuria, abnormal PV discharge, breast tenderness, lumps, or nipple discharge. 

ALLERGIES: Denies, hives, eczema, or rhinitis.

O.

Physical exam:

Vital signs: BP-120/80; HR-78; RR-16; Temp-98.4

Height- 5’0; Weight-172 lbs.; BMI-33.6

Neurologic: CNs are intact. Muscle strength- 5/5. Perineal reflexes are present.

GENITOURINARY: Normal female genitalia. Pad test-Positive

Diagnostic results: No tests were ordered.

A.

Primary and Differential Diagnoses

Urinary Incontinence:  This is characterized by an involuntary loss of urine severe enough to cause social or hygienic problems (O’Connor et al., 2021). The patient reports urinary leakage that forces her to wear a pad. The leakage interferes with her occupational functioning. This makes Urinary incontinence the priority diagnosis for this patient.

Overactive bladder (OAB): The hallmark symptom of OAB is urinary urgency. Some patients may experience urgency urinary incontinence (Scarneciu et al., 2021). Urinary frequency and nocturia are usually present. The patient has urinary incontinence making OAB a differential diagnosis.

Bladder Dysfunction: This is a complication of chronic low back pain. Bladder dysfunction is characterized by urinary incontinence, hesitancy, dysuria, urgency, frequency, recurrent urinary tract infections (UTIs), and nocturia (Hughes & May, 2020).  This is a differential diagnosis based on the patient’s urinary leakage, which forces her to frequently visit the bathroom.

P.

Diagnostic Studies: Diagnostic tests that should be ordered include urinalysis and urine culture to rule out UTI.

Kidney function studies like Blood urea nitrogen (BUN) and creatinine are important to rule out kidney failure (Sharma & Chakrabarti, 2018).

Electromyography (EMG) is essential to establish whether the patient’s voiding is coordinated or uncoordinated (Sharma & Chakrabarti, 2018).

A voiding cystourethrogram (VCUG) may be ordered to examine the size, shape, support, and function of the urinary bladder (Sharma & Chakrabarti, 2018).

Treatment Options:

  1. Anticholinergic agents: Propantheline bromide 30 mg every 6 hours.

Anticholinergics are used in Urinary incontinence because they increase bladder capacity, increase the volume threshold for initiation of an involuntary contraction,  and reduce the strength of involuntary bladder contractions (O’Connor et al., 2021).

  1. Antispasmodic agents: Trospium (Sanctura) 20 mg twice daily.

Trospim has antispasmodic and antimuscarinic effects and is indicated to treat urinary incontinence, urgency, and frequency (McKinney et al., 2022).

  1. Tricyclic antidepressants (TCAs): Imipramine 50 mg OD.

Imipramine facilitates urine storage by reducing bladder contractility while increasing outlet resistance (O’Connor et al., 2021). 

Non-pharmacological Interventions

  1. Pelvic floor (Kegel) exercise therapy: To strengthen pelvic floor muscles.
  2. Use of anti-incontinence devices (McKinney et al., 2022).
  3. Nutrition therapy for weight reduction. This is helpful for obese patients since stress incontinence is worsened by increased abdominal pressure from obesity (Yazdany et al., 2020).

Referral: Urology consultation.

Follow-up: Schedule follow-up after two weeks.

Reflection: The assignment enlightened me about urinary incontinence. I have realized that many individuals suffer in silence from this condition and are socially isolated. In a different situation, I would detail the symptoms of urinary incontinence including leakage, frequency, urgency, and nocturia. I would also obtain a 24-hour intake and output record or a voiding diary. Health promotion should focus on weight loss since obesity has been identified as a risk factor for the development of urinary incontinence (Yazdany et al., 2020). Thus, interventions to manage obesity can result in improved continence

References

Hughes, C., & May, S. (2020). A directional preference approach for chronic pelvic pain, bladder dysfunction, and concurrent musculoskeletal symptoms: a case series. The Journal of Manual & manipulative therapy, 28(3), 170–180. https://doi.org/10.1080/10669817.2019.1668994

McKinney, J. L., Keyser, L. E., Pulliam, S. J., & Ferzandi, T. R. (2022). Female Urinary Incontinence Evidence-Based Treatment Pathway: An Infographic for Shared Decision-Making. Journal of Women’s Health (2002), 31(3), 341–346. https://doi.org/10.1089/jwh.2021.0266

 O’Connor, E., Nic An Riogh, A., Karavitakis, M., Monagas, S., & Nambiar, A. (2021). Diagnosis and Non-Surgical Management of Urinary Incontinence – A Literature Review with Recommendations for Practice. International Journal of general medicine, 14, 4555–4565. https://doi.org/10.2147/IJGM.S289314

 Scarneciu, I., Lupu, S., Bratu, O. G., Teodorescu, A., Maxim, L. S., Brinza, A., Laculiceanu, A. G., Rotaru, R. M., Lupu, A. M., & Scarneciu, C. C. (2021). Overactive bladder: A review and update. Experimental and therapeutic medicine, 22(6), 1444. https://doi.org/10.3892/etm.2021.10879

Sharma, N., & Chakrabarti, S. (2018). Clinical Evaluation of Urinary Incontinence. Journal of mid-life health, 9(2), 55–64. https://doi.org/10.4103/jmh.JMH_122_17

 Yazdany, T., Jakus-Waldman, S., Jeppson, P. C., Schimpf, M. O., Yurteri-Kaplan, L. A., Ferzandi, T. R., Weber-LeBrun, E., Knoepp, L., Mamik, M., Viswanathan, M., Ward, R. M., & American Urogynecologic Society (2020). American Urogynecologic Society Systematic Review: The Impact of Weight Loss Intervention on Lower Urinary Tract Symptoms and Urinary Incontinence in Overweight and Obese Women. Female pelvic medicine & reconstructive surgery, 26(1), 16–29. https://doi.org/10.1097/SPV.0000000000000802

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Week 8 Case Studies

Case Study 1

Mable Albright is a 48-year-old, native American who presents to your clinic with the complaint of urinary leakage. She relates this has been worsening over the past 2 years. She now must wear a pad all the time and states it is interfering with her work as she is going to the bathroom all the time. Medical history is negative, surgical history is remarkable for wisdom teeth and a bilateral tubal ligation.

VSS: and normal

5’0 172 lbs. (BMI 33.6)

Case Study 2

Shirley Jackson is a 29-year-old female presenting today at your clinic with a positive home pregnancy test. Her medical history is negative. Surgical history negative. Gyn history 1st menses age 12, with cycles coming every 28 days and lasting for 5 days. Her pap and std history are negative. She has been taking a woman’s gummy vitamin for the past year. Her OB history is

 

Date

gestation

outcome

gender

wt.

anesthesia

complications

1-2011

6

TAB

None

4-2014

39

Low forceps delivery

male

8’14”

epidural

Gestational diabetes

5-2016

8 weeks

SAB

8-2016

35 weeks

twins

NSVD

Female

Female

6’6”

7’1”

epidural

Di/di twins

7-2017

38 weeks

SVD

male

8’10”

local

Gestational diabetes

Shirley relates her last period (LMP) was 4/24/2023. She reports breast tenderness, fatigue, and nausea (which is what made her suspect she was pregnant).

Smoking/Alcohol/recreational drug use. Any potential chemical exposures at home or work. Social history such as relationship status, living situation, support system, job type, dietary restrictions.

Update: Height, weight, vital signs

Shirley denies smoking, alcohol, and recreational drug use. She is a warehouse supervisor at Amazon and works 36 hrs. per week. She and her fiancé have been together for 5 years, and he works in an accounting office. They live in a 3-bedroom townhouse within easy walking distance to schools and stores. Her fiancé’s parents live in the same complex they do, and her parents and younger sister live about a mile away. Phillipa relates she is become a vegetarian since her last pregnancy.

Her vital signs at her first visit height 5’4” weight 176 lbs. and her BP are 112/68

Case Study 3

Bonita Bubble is a 39-year-old female presenting today at your clinic with a positive home pregnancy test. Her medical history is negative. Surgical history is remarkable for a c section. Gyn history 1st menses age 12, with cycles coming every 28 days and lasting for 5 days. Her pap and std history are negative. She has been taking a woman’s vitamin for the past 6 years. Her OB history is:

Date

gestation

outcome

anesthesia

Length of labor

weight

gender

complications

1-2015

41 weeks

nsvd

epidural

18

7’6

female

none

2-2016

37 weeks

nsvd

epidural

6

7’11”

femal

Disappearing twin

3-2017

39 weeks

Primary c/s

spinal

na

8’2”

male

c/s for breech after failed version

3-2019

6 weeks

ectopic

Treated with methotrexate

Bonita relates her last period (LMP) was 4/24/2023. She reports breast tenderness, fatigue, and nausea (which is what made her suspect she was pregnant).

Common Health Conditions with Implications for Women

Case studies provide the opportunity to simulate realistic scenarios involving patients presenting with various health problems or symptoms. Such case studies enable nurse learners to apply concepts, lessons, and critical thinking to interviewing, screening, and diagnostic approaches, as well as to the development of treatment plans.

For this Case Study Discussion, you will propose a differential diagnosis with a minimum of 3 possible conditions or diseases. You will prioritize these diagnoses and explain which you would recommend.

Resources

Be sure to review the Learning Resources before completing this activity.

Click the weekly resources link to access the resources.

WEEKLY RESOURCES

Learning Resources

Required Readings

Schuiling, K. D., & Likis, F. E. (2022). Gynecologic health care (4th ed.). Jones and Bartlett Learning.

Chapter 17, “Breast Conditions” (pp. 337-349)

Chapter 32, “Anatomy and Physiologic Adaptations of Normal Pregnancy” (pp. 677–673)

Chapter 19, “Pregnancy Diagnosis, Decision-Making support, and Resolution” (pp. 367-379

General Guidelines for Health Screenings

American Academy of Family Practice (AAFP). (2020). Browse AAFP clinical recommendations

Links to an external site.. https://www.aafp.org/home.html

American Cancer Society, Inc. (ACS). (2020). Cancer A-Z

Links to an external site.. https://www.cancer.org/

Note: As you review this resource, select the “Cancer A-Z” topic in the navigation to review information and Resources about for Cancer: Breast, Colon, Lung, Prostate, Skin.

American College of Obstetricians and Gynecologists (ACOG). (2020). Clinical topics

Links to an external site.. https://www.acog.org/

Note: As you review this source, make sure to navigate to the “Topics” section in the navigation to review the clinical topics.

HealthyPeople 2030. (2020). Healthy People 2030 Framework

Links to an external site.. https://www.healthypeople.gov/2020/About-Healthy-People/Development-Healthy-People-2030/Framework

U.S. Preventive Services Task Force (USPTFS). (2017, September). Search and Filter All Recommendation Topics

Links to an external site.. https://www.uspreventiveservicestaskforce.org/uspstf/topic_search_results?topic_status=P&searchterm=

FNP Resources

Centers for Disease Control and Prevention. (CDC). (n.d.). Disease & conditions

Links to an external site.. https://www.cdc.gov/DiseasesConditions/

The American Association of Nurse Practitioners (AANP). (2020). AANP practice: Clinical Resources, Business, acumen and opportunities for professional recognition

Links to an external site.. https://www.aanp.org/practice

Geriatric Resources

Nicholas, J. A., & Hall, W. J. (2011). Screening and preventive services for older adults

Links to an external site.. The Mount Sinai Journal of Medicine, New York, 78(4), 498–508. https://go.openathens.net/redirector/waldenu.edu?url=https://doi.org/10.1002/msj.20275

Document: Focused SOAP Note Template

Download Focused SOAP Note Template (Word document)

Document: General Guidelines for Health Screenings Matrix Template

Download General Guidelines for Health Screenings Matrix Template (Word document)

Required Media

Common Health Conditions

Dr. Anne Salomone reviews and discusses the topics found in Weeks 7 & 8 (40 mins).

Optional Resources

Note: In Weeks 1-10, these resources are optional for your review. In Week 11, you will be required to review each of the PowerPoint slides from the text Gynecologic Health Care (4th ed.).

Chapter 17, “Breast Conditions

Download Breast Conditions”

Chapter 32, “Anatomy and Physiologic Adaptations of Normal Pregnancy

Download Anatomy and Physiologic Adaptations of Normal Pregnancy”

Chapter 19, “Pregnancy Diagnosis, Decision-Making support, and Resolution

Download Pregnancy Diagnosis, Decision-Making support, and Resolution”

To prepare:

By Day 1 of this week, you will be assigned to a specific scenario for this Discussion. Please see the “Course Announcements” section of the classroom for your assignment from your Instructor.

Review the Learning Resources for this week as well as Weeks 5 and 6 and specifically review the clinical guideline resources specific to your assigned case study.

Use the Focused SOAP Note Template found in the Learning Resources to support Discussion. Based on the case study scenario provided, complete a SOAP note and critically analyze this and focus your attention on the diagnostic tests.

By Day 3

Based on your assigned case study, post a Focused SOAP NOTE with the following:

Differential diagnosis (dx) with a minimum of 3 possible conditions or diseases.

Define what you believe is the most important diagnosis. Be sure to include the first priority in conducting your assessment.

Explain which diagnostic tests and treatment options you would recommend for your patient and explain your reasoning.

Your differential diagnosis, what you believe the most important diagnosis is and why, additional diagnostic tests and treatments and rationales are what this assignment and grading is focused on. Your critical thinking for this assignment

Read a selection of your colleagues’ responses.

By Day 6

Respond to at least two of your colleagues’ posts on two different days and explain how you might think differently about the types of tests or treatment options your colleagues suggested and why. Use your learning resources and/or evidence from the literature to support your position.

Note: For this Discussion, you are required to complete your initial post before you will be able to view and respond to your colleagues’ postings. Begin by clicking on the Reply button to complete your initial post. Remember, once you click on Post Reply, you cannot delete or edit your own posts and you cannot post anonymously. Please check your post carefully before clicking on Post Reply!

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