NURS 6512 LAB ASSIGNMENT: ASSESSING THE GENITALIA AND RECTUM

Health assessment, such as the one in NURS 6512 LAB ASSIGNMENT: ASSESSING THE GENITALIA AND RECTUM, helps clinicians develop the most effective care plan from clinical reasoning, diagnosis, and treatment of the patient effective, based on the provided information. For instance, when carrying out a genitourinary assessment of a patient, it is very important to base the investigations on the patient’s subjective data and diagnostic examination (Chen & Zeng, 2020). The provided case study for this assignment presents a 32-year-old female patient with a chief complaint of frequency, dysuria, and urgency for the past two days. A thorough health assessment is required for further understanding of the condition the patient is suffering from to promote the development of an appropriate care plan. Hence, this NURS 6512 LAB ASSIGNMENT: ASSESSING THE GENITALIA AND RECTUM paper aims at exploring additional subjective and objective information necessary to promote the diagnosis process of this patient.

Additional Subjective Information

The subjective information provided by the patient includes the chief complaint of increased urine frequency, urgency, and painful urination. Following the acronym “OLD CARTS” for further elaboration of the patient’s chief complaint, only the onset, and location of the symptoms have been provided since the patient reports having the above symptoms for the past two days (Kim et al., 2019). However, additional information regarding the patient presenting symptoms such as severity, alleviating, and aggravating factors are also crucial in promoting further understanding of the patient’s condition.

Under current patient medication, the patient reports not taking any medication at the moment for the present condition or any other medical condition. However, information regarding the patient’s allergies and past medical history are missing (Chen & Zeng, 2020). The patient also reports a history of tonsillectomy in 2001, and appendectomy in 2020, which are essential aspects of the patient’s subjective information. The immunization status of the patient is however missing, which is crucial in understanding the cause of the patient’s condition and how it should be managed.

The patient’s social and family history are also missing, which are crucial in determining the risk factors which predispose the patient to certain medical conditions. Additionally, the patient’s reproductive history is also missing, such as the menstrual cycle is also missing, in addition to health maintenance such as eating habits and sleeping patterns (Paladine & Desai, 2018). Finally, the review of systems for this patient is also missing. This information is crucial for further understanding the normal functioning of different body systems, to determine which systems have been affected by the patient’s condition.

Additional Objective Information

The objective information is usually collected upon conducting a physical examination of the patient while focusing only on pertinent data to the reported patient’s chief complaint. The clinician needs to start by evaluating the patient’s general health by describing their general appearance such as alert, fatigued, or well-groomed (Kim et al., 2019). The patient’s vitals dada has been provided, but still lacks information on the patient’s height and weight which is needed in calculating her BMI and determining if she has an ideal body weight, obese, overweight, or underweight. Cardiovascular and respiratory examination findings are also necessary for determining the functioning of the two systems, of which abnormalities are associated with poor health and increased risk of infections.

Additionally, since the patient presents with symptoms of a genitourinary disease, it is quite crucial to conduct a comprehensive examination of the genitourinary system. Mild tenderness of the suprapubic area was reported, in addition to the absence of vaginal discharge and adnexal tenderness. Upon conducting the pelvic bimanual examination, it was noted that the patient had normal-sized adnexa and uterus with a normal cervix in appearance. In addition to this information, the characteristic of the patient’s urine, in terms of appearance and odor should have also been provided for further understanding of the condition the patient is suffering from (Charvériat & Fritel, 2019). The reported objective information is necessary in guiding the type of diagnostic tests to order to promote an accurate diagnosis of the patient.

Assessment

The provided subjective and objective information relatively supports the assessment of the patient which suggests the presence of urinary tract infection (UTI). The patient is positive for UTI symptoms such as increased frequency and urgency and pain during urination as demonstrated in the subjective portion of the patient’s history. Additional UTI symptoms include foul-smelling and cloudy urine among others (Paladine & Desai, 2018). The objective portion of the patient history on the other hand reveals mild tenderness in the suprapubic region which might have resulted from urine retention confirming the presence of an infection. However, urinalysis and urine culture are required to confirm this assessment.

Diagnostics Appropriateness

Given that most genitourinary diseases she common symptoms such as increased urgency and frequency, certain diagnostic tests are needed for the clinician to be able to come up with an accurate diagnosis. Such tests include urinalysis, to assess for the presence of a bacteria, virus, or any other causative microorganism (Kim et al., 2019). A urine culture is needed to determine the type of bacteria causing the infection. Consequently, a cystoscopy test is also necessary to examine infections of the urethra and bladder and determine the cause of the urinary tract infection.