NRNP 6552 COMMON GYNECOLOGIC CONDITIONS, PART 2 Paper

NRNP 6552 COMMON GYNECOLOGIC CONDITIONS, PART 2 Paper

NRNP 6552 COMMON GYNECOLOGIC CONDITIONS, PART 2 Paper

Common Gynecologic Conditions, Part 2

 Episodic/Focused SOAP Note

Patient Information:

Initials: H.T.               Age: 79 years old                 Sex: Female              Race: Caucasian.

S.

CC (chief complaint):”Constipation and vaginal bleeding for the past three weeks.”

HPI: L.K. is a 79-year-old woman, who arrived at the clinic complaining of constipation and persistent vaginal bleeding. She claims to have pelvic pain and a feeling that something is trying to escape from that area. She asserts that staying up too long only makes the condition worse. She continues by saying that lying down helps the condition. Her back and stomach have been hurting for the past three to four months. She claims that a lump in the shape of a ball protrudes from her vagina and that it hurts. She claims that she has been experiencing constipation for the past three weeks. She asserts that she has never used powders, sprays, or genital douching. 

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Location: Pelvic region

Onset: 3 weeks ago

Character: She feels like something trying to wriggle out of her pelvis as well as pelvic pain.

Associated signs and symptoms: Constipation, back pain, and stomach discomfort

Timing: Throughout the day

Exacerbating/relieving factors: Laying down makes the pain go away.

Severity: 6/10 pain scale

Current Medications: For pain relief, she takes 400 mg of ibuprofen orally every 6 to 8 hours.

Allergies:denies having food, drug, or environmental allergies.

PMHx:

• Backache is on the list of ailments
• Preventive medicine: Her immunization records are up to date.
• Hospitalizations: It was stated that the patient was brought to the hospital in 2012 as a result of persistent back discomfort, which led to the condition’s first diagnosis.

Soc& Substance Hx:L.K. has had two sons and one daughter throughout his marriage. Five years after the death of her spouse, the patient moved to the suburbs since she was unable to maintain her children in the city. She runs the grocery store owned by her family. She asserts that she eats a full meal each day and gets adequate sleep every night. The patient states that she tries to exercise for 30 minutes at the gym at least three times a week. However, she does not follow a healthy diet. She sleeps for six to eight hours every night.

Fam Hx:

Grandfather on my mother’s side passed away at age 65 and had a history of high cholesterol and blood pressure.

His maternal grandmother had a history of asthma and passed away at the age of 77.

Grandfather on my mother’s side passed away in an automobile accident at the age of 56.

Grandmother-in-law—died of renal failure at the age of 44.

Father- diabetes and hypertension; passed away at 46.

Mother- died at the age of 79 from causes associated with hyperlipidemia

Sister- At age 66, has a history of diabetes and high blood pressure.

Surgical Hx:denies any previous surgical history.

Mental Hx: Denies having ever experienced sadness or anxiety. denies ever using self-harm or having thoughts of suicide or homicide.

Violence Hx: Denies any worries about personal, domestic, or public safety. denies any previous incidents of sex or physical abuse.

Reproductive Hx:Heterosexual. age 45 onset of menopause. history of negative STI/HIV tests. normal birth, married, and three children. She claims that she has a Pap test every three to four years, with her most recent one having taken place four years before. She claims that all of her Pap smear test results have been normal.

ROS:

GENERAL:Complaints of constipation and pelvic discomfort. denies experiencing weakness, weariness, fever, or chills.

HEENT:Eyes: Denies having any visual loss, double vision, vision impairment, or yellow sclera. Denies experiencing hearing loss, cold symptoms, runny or stuffy nose, or hoarseness.

SKIN: Denies having a rash or irritation.

CARDIOVASCULAR: Denies experiencing any chest pressure, pain, or discomfort. No palpitations or edema.

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

GASTROINTESTINAL:Complaints of pain and constipation. denies having anorexia, motion sickness, or diarrhea.

NEUROLOGICAL: Denies feeling any pains, tingling, vertigo, fainting, paralysis, ataxia, or headaches. No changes to bowel or bladder control.

MUSCULOSKELETAL: Denies experiencing stiffness, joint discomfort, back pain, or muscular pain.

HEMATOLOGIC: Denies bruising, bleeding, or anemia.

LYMPHATICS: Denies the existence of bigger nodes. There was no previous splenectomy history.

PSYCHIATRIC: Denies a past filled with worry or sadness.

ENDOCRINOLOGIC: Denies cold, heat, and perspiration. No polyuria/polydipsia.

GENITOURINARY/REPRODUCTIVE:three weeks of vaginal bleeding and constipation. She claims that something thrilling is pressing on her pelvis. She also laments her vaginal edema. Her last Pap smear was four years ago. She maintains her Pap smear tests were normal.

ALLERGIES:denies having ever had hay fever, hives, eczema, or asthma.

O.

Vital Signs:   HR: 84           BP: 136/81       Temp: 98.9  RR: 16      SpO2: 99.4           Pain:6/10

Height: 5’7     Weight: 152 lbs.       BMI: 23.80

Physical exam:

General: There are no additional symptoms, such as fever, chills, weight loss, nocturnal sweating, sleepiness, or fatigue.

Breast: No dimpling, retraction, inflammation, or soreness, small breasts, symmetrical nipples, unmodified nipples, or areola. Skin that is unharmed, without nipple discharge, or wrinkles.

Abdomen:  There are no visible lumps, dilated veins, or anomalies. The location of the umbilicus seems to be normal. Stretch marks are visible, a cesarean scar may be seen, and the breathing patterns of the various quadrants are comparable. There were no other strain origins discovered.

Genitourinary/Gynecological: A lower posterior vaginal wall bulge is seen during a vaginal examination with a Sims speculum, and the vaginal walls are pink and badly graded. There are no lesions or ulcerations on the external genitalia, just a triangular patch of coarse pubic hair with a normal distribution. An enlarging mass was seen when the rectocele was examined. The rectum is inspected using a rectal finger. It demonstrates a rectocele.

Diagnostic results:A comprehensive blood analysis was requested to investigate potential underlying medical conditions. To ascertain the dimensions of the tissue protrusion, a medical professional prescribed either an X-ray or an MRI scan. The patient was recommended to undergo defecography (Bharucha & Knowles, 2022).

A.

Differential Diagnosis

• Rectocele (N81. 6): Rectocele is defined by the anterior and posterior walls of the vagina protruding simultaneously. Some rectoceles may not exhibit any symptoms at all, while others, like the one this man has, unquestionably do (Aubert et al., 2021). Pelvic pressure, uncomfortable sexual encounters, tummy and low back pain, uterine hemorrhage, and a protruding lump of the rectocele were some of the patient’s symptoms. The patient also had a tumor that was visible through their rectocele.
• Uterovaginal prolapse (4): The patient arrived with uterine prolapse symptoms such vaginal bleeding, constipation issues, feeling full, vaginal bleeding, and pain during sex. These signs and symptoms are associated with uterine prolapse (Deshpande et al., 2023). On the other hand, the examination of the rectum disqualifies this as a possibility.
• Ovarian Cysts (20): Engaging in sexual activity may result in discomfort, abdominal heaviness, and potential bleeding in the event of ovarian cyst presence and subsequent rupture. The findings from the physical examination and rectum examination conducted by Gottschau et al. (2019) provide evidence that contradicts the existence of this condition.

Primary Diagnosis: Rectocele (N81. 6)   

P.

1. Rectocele (N81. 6)             

1. Requesting a pelvic exam that includes a vaginal and rectal examination is wise. To examine the rectum’s wall closest to the vagina, a digital rectal exam will be conducted. Defecography, a specialized X-ray, may also confirm a rectocele (Bharucha & Knowles, 2022).
2. Premarin, an estrogen-conjugated drug, should be taken once a day at a dose of 0.3 milligrams (Bharucha & Knowles, 2022).
3. Every day, the patient’s diet has to contain whole grains, legumes, fruits, and vegetables. These foods are high in fiber (Bharucha & Knowles, 2022).
4. Encourage the patient to drink a lot of water (Yao et al., 2021).
5. Encourage the patient to do some kind of physical activity every day (Yao et al., 2021).
6. After four weeks, tell the patient to come back in for a follow-up evaluation of the treatment’s efficacy.

Reflection: For gynecological illnesses like rectocele, a significant quantity of data from the patient’s experience is needed in addition to the test results to confirm the initial diagnosis. Given that pelvic discomfort and vaginal bleeding are frequent symptoms of gynecological diseases, it was difficult to make the initial diagnosis for this patient based on the factual and subjective information supplied. Regarding a thorough assessment of the patient’s diagnosis and proposed course of therapy, a urogynecologist should be contacted (Aubert et al., 2021). For example, surgery is the most effective treatment for rectocele. To encourage the patient’s autonomy, it is crucial to inform them of the many treatment possibilities. Additionally, the patient should be made aware of the value of nutrition and exercise in enhancing health and quality of life.

References

Aubert, M., Mege, D., Le Huu Nho, R., Meurette, G., & Sielezneff, I. (2021). Surgical management of the rectocele – An update. Journal of Visceral Surgery, 158(2), 145–157. https://doi.org/10.1016/j.jviscsurg.2020.10.001

Bharucha, A. E., & Knowles, C. H. (2022). Rectocele: Incidental or important? Observe or operate? Contemporary diagnosis and management in the multidisciplinary era. 34(11). https://doi.org/10.1111/nmo.14453

Deshpande, R. R., Matsuzaki, S., Cox, K. R., Foy, O. B., Mandelbaum, R. S., Ouzounian, J. G., Dancz, C. E., & Matsuo, K. (2023). Incidence, characteristics, and maternal outcomes of pregnancy with uterine prolapse. American Journal of Obstetrics & Gynecology MFM, 101020. https://doi.org/10.1016/j.ajogmf.2023.101020

Gottschau, M., Jensen, A., Reinholdt, K., Guleria, S., Munk, C., Mellemkjær, L., & Kjær, S. K. (2019). Risk of breast cancer among women with benign ovarian tumors: a Danish nationwide cohort study. Breast Cancer Research and Treatment, 178(1), 199–205. https://doi.org/10.1007/s10549-019-05369-8

Yao, Y.-B., Yin, H., Wang, H.-J., Liang, H., Wang, B., & Wang, C. (2021). Is the transperineal ultrasonography approach effective for the diagnosis of rectocele? https://doi.org/10.1093/gastro/goab019

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COMMON GYNECOLOGIC CONDITIONS, PART 2

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, diagnostic approaches, as well as to the development of treatment plans.

For this Case Study Discussion, you will develop a case study that demonstrates a gynecological disease process from your practicum experience or your professional practice that would be quite challenging for you as a clinician. You will then explore this case study to determine the diagnosis, diagnostic tests, and treatment options for the patient

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 23, “Urinary Tract Infections” (pp. 469–478)

Chapter 24, “Urinary Incontinence” (pp. 479–492)

Chapter 23, “Menstrual-Cycle Pain and Premenstrual Syndrome” (pp. 495–510)

Chapter 26, “Normal and Abnormal Uterine Bleeding” (pp. 511–526)

RESOURCES FOR LGBTQ+

Aisner, A. J., Zappas, M., & Marks, A. (2020). Primary Care for Lesbian, Gay, Bisexual, Transgender, and Queer/Questioning (LGBTQ) PatientsLinks to an external site.. The Journal for Nurse Practitioners, 16(4), 281–285. https://go.openathens.net/redirector/waldenu.edu?url=https://doi.org/10.1016/j.nurpra.2019.12.011

Office of Disease Prevention and Health Promotion (ODPHP). (2020, April 18). Lesbian, gay, bisexual, and transgender healthLinks to an external site.. https://www.healthypeople.gov/2020/topics-objectives/topic/lesbian-gay-bisexual-and-transgender-health

Sadlak, C. A., Boyd, C. J., & Lesbian, Gay, Bisexual, Transgender, Queer (LGBTQ)

Health Expert Panel (2016). American Academy of Nursing on Policy: Health care services for transgender individuals: Position statementLinks to an external site.. https://www.nursingoutlook.org/action/showPdf?pii=S0029-6554%2816%2930120-8

Wingo, E., Ingraham, N., & Roberts, S. C. M. (2018). Reproductive Health Care Priorities and Barriers to Effective Care for LGBTQ People Assigned Female at Birth: A Qualitative StudyLinks to an external site.. Women’s Health Issues, 28(4), 350–357. https://go.openathens.net/redirector/waldenu.edu?url=https://doi.org/10.1016/j.whi.2018.03.002

FNP RESOURCES

American Academy of Nurse Practitioners Certification Board (AANPCB). (2018). Welcome to the American Academy of Nurse Practitioners Certification BoardLinks to an external site.. https://www.aanpcert.org/

American Academy of Nurse Practitioners National Certification Board, Inc. (AANPCB). (2018). FNP & AGNP Certification Candidate HandbookLinks to an external site.. https://www.aanpcert.org/resource/documents/AGNP%20FNP%20Candidate%20Handbook.pdf

CLINICAL GUIDELINE RESOURCES

As you review the following resources, you may want to include a topic in the search area to gather detailed information (e.g., breast cancer screening guidelines; CDC for zika in pregnancy, etc.).

American Cancer Society, Inc. (ACS). (2020). Information and Resources about Cancer: Breast, Colon, Lung, Prostate, SkinLinks to an external site.. https://www.cancer.org/

American College of Obstetricians and Gynecologists (ACOG)Links to an external site.. (2020). https://www.acog.org/

American Nurses Association (ANA). (n.d.). Lead the profession to share the future of nursing and health careLinks to an external site.. https://www.nursingworld.org/

Centers for Disease Control and Prevention. (CDC). (n.d.). CDC in actionLinks to an external site.. https://www.cdc.gov

HealthyPeople 2030. (2020). Healthy People 2030 FrameworkLinks to an external site.. https://www.healthypeople.gov/2020/About-Healthy-People/Development-Healthy-People-2030/Framework

The American Association of Nurse Practitioners (AANP). (2020). What’s Happening at your associationLinks to an external site.. https://www.aanp.org/

Document: Focused SOAP Note Template Download Focused SOAP Note Template(Word document)

Optional Resources

Kelsey, B. M. & Nagtalon-Ramos, J. (2021). Midwifery & Women’s Health Nurse Practitioner Certification Review Guide (5th ed.). Jones & Bartlett Learning.

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 23, “Urinary Tract Infections Download Urinary Tract Infections”

Chapter 24, “Urinary Incontinence Download Urinary Incontinence”

Chapter 25, “Menstrual-Cycle Pain and Premenstrual Syndrome Download Menstrual-Cycle Pain and Premenstrual Syndrome”

Chapter 26, “Normal and Abnormal Uterine Bleeding Download Normal and Abnormal Uterine Bleeding”

To prepare:

Consider a case study related to a patient that demonstrates a gynecological disease process in your practicum experience or professional practice that would be your biggest challenge as a clinician. Note: Possibly use your “FNP or AGPCNP Skills and Procedures Self-Assessment” in your practicum experience to guide your case study selection.

Review the Learning Resources for this week and specifically review the clinical guideline resources specific to your proposed case study.

Use the Focused SOAP Note Template found in the Learning Resources to support your discussion. Complete a Focused SOAP note and critically analyze this and focus your attention on the diagnostic tests.

BY DAY 3

Based on your case study, post the following:

POST A Focused SOAP NOTE only and describe your case study.

Provide a 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 priority in conducting your assessment.

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

Also, share with your colleagues your experiences as well as what you learned from these experiences.

Use your Learning Resources and/or evidence from the literature to support your thinking and perspectives.

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 that 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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