Advance Assessment

The Ethics Behind Assessment

 

Review the scenarios provided by your instructor and choose one for this week’s Assignment. 

Scenario 1

A 17-year-old boy has come in for a check-up after a head injury during a football game. He has indicated that he would like to be able to play in the next game, which is in 3 days.

Scenario 2

A 12-year-old girl has come in for a routine check-up and has not yet received the HPV vaccine. Her family is very religious and believes that the vaccine would encourage premarital sexual activity.

Scenario 3

A single mother has accompanied her two daughters, aged 15 and 13, to a women’s health clinic and has requested that the girls receive a pelvic examination and be put on birth control. The girls have consented to the exam but seem unsettled.

 

Based on the scenario you choose

What necessary information would need to be obtained about the patient through health assessments and diagnostic tests?

Consider how you would respond as an advanced practice nurse. Review evidence-based practice guidelines and ethical considerations applicable to the scenarios you selected.

The Assignment

Write a detailed one-page narrative (not a formal paper) 

  • Explaining the health assessment information required for a diagnosis of the patient in the scenario (include the scenario number). 
  • Explain how you would respond to the scenario as an advanced practice nurse using evidence-based practice guidelines and applying ethical considerations. 
  • Justify your response using at least three different references from current evidence-based literature.
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Advance Assessment

Assessing the Genitalia and Rectum

 

Evaluate abnormal findings on the genitalia and rectum

Apply concepts, theories, and principles relating to health assessment techniques and diagnoses for the breasts, genitalia, prostate, and rectum

 

To Prepare

Please make sure to write this assignment up in narrative form (Refer to your Week 6 Abdomen Lab Assignment for feedback so that you do not make the same mistakes on this one). 

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.

 

 

The Lab Assignment

 

Using evidence-based resources from your search, answer the following questions and support your answers using current evidence from the literature.

 

Address all of the following questions in great detail- use these as headings for the narrative for your assignment

 

  • 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 five 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

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

Assessment:

UTI

STD

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Advance Assessment

A 30yr Obese African American Pt states, “I came in because I am required to have a physical exam for the health insurance at my new job” – offers no specific/acute complaints. States she has been hired as an accounting clerk. Last medical exam 5 months ago at this facility Dx DM2 controlled with metformin, exercise & diet. Saw OBGYN last week for PAP smear Dx polycystic ovarian disease.

 

Medications: Patient takes metformin 850mgbid ethinyl estradiol for birth control /PCOS Flovent 2 puffs twice daily Asthma albuterol recue inhalers last used 3 months ago related to cat exposure Advil OTC – cramps last taken 6 weeks ago

Give five differential diagnoses for the above patient

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Advance Assessment

Assignment- Case Study- Assessing Neurological Symptoms With regard to the case study, you were assigned:

 

CASE STUDY 2: Numbness and Pain

A 47-year-old obese female complains of pain in her right wrist, with tingling and numbness in the thumb and index and middle fingers for the past 2 weeks. She has been frustrated because the pain causes her to drop her hair-styling tools.

.

•        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 and justify why you selected each. You will be making up the information that is missing to complete this soap note.

 Provide evidence from the literature to support diagnostic tests that would be appropriate for each case. 

 

The Case Study Assignment

Use the Episodic/Focused SOAP Template and create an episodic/focused note about the patient in the case study to which you were assigned using the episodic/focused note template provided.

 

 

Please Note: The Template considered 3 Pages

Differential diagnoses should be 2 pages

Check your work for originality please(very important) The Rubric is a guide

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Advance Assessment

A 46-year-old female reports pain in both of her ankles, but she is more concerned about her right ankle. She was playing soccer over the weekend and heard a “pop.” She is able to bear weight, but it is uncomfortable. In determining the cause of the ankle pain, based on your knowledge of anatomy, what foot structures are likely involved? What other symptoms need to be explored? What are your differential diagnoses for ankle pain? What physical examination will you perform? What special maneuvers will you perform? Should you apply the Ottawa ankle rules to determine if you need additional testing?

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