Assignment: Distended Bladder
Assignment: Distended Bladder
Assignment: Distended Bladder
General Appearance Healthy-appearing adult female in no acute distress. Alert and oriented; answers questions appropriately. Slightly somber affect at first and then brighter later. Skin Skin is brown, warm, dry, clean, and intact. No rashes or lesions noted. HEENT Head is normocephalic, atraumatic, and without lesions; hair evenly distributed. Eyes: PERRLA. EOMs intact. No conjunctival or scleral injection. Ears: Canals patent. Bilateral TMs pearly gray with positive light reflex; landmarks easily visualized. Nose: Nasal mucosa pink; normal turbinates. No septal deviation. Neck: Supple. Full ROM; no cervical lymphadenopathy; no occipital nodes. No thyromegaly or nodules. Oral mucosa, pink and moist. Pharynx is nonerythematous and without exudate. Teeth are in good repair. Cardiovascular S1, S2 with regular rate and rhythm. No extra sounds, clicks, rubs, or murmurs. Capillary refills two seconds. Pulses 3+ throughout. No edema. Respiratory Symmetric chest wall. Respirations regular and easy; lungs clear to auscultation bilaterally. Gastrointestinal Abdomen obese; BS active in all the four quadrants. Abdomen soft, nontender. No hepatosplenomegaly. Breast Breast is free from masses or tenderness, no discharge, no dimpling, wrinkling, or discoloration of the skin. Genitourinary Bladder is nondistended; no CVA tenderness. External genitalia reveals coarse pubic hair in normal distribution; skin color is consistent with general pigmentation. No vulvar lesions noted. Well estrogenized. A small speculum was inserted; vaginal walls are pink and well rugated; no lesions noted. Cervix is pink and nulliparous. Scant clear to cloudy drainage present. On bimanual exam, cervix is firm. No CMT. Uterus is antevert and positioned behind a slightly distended bladder; no fullness, masses, or tenderness. No adnexal masses or tenderness. Ovaries are nonpalpable. (Male: Both testes are palpable, no masses or lesions, no hernia, and no uretheral discharge.) (Rectal as appropriate: No evidence of hemorrhoids, fissures, bleeding, or masses—Males: Prostrate is smooth, nontender, and free from nodules, is of normal size, and sphincter tone is firm). Musculoskeletal Full ROM seen in all four extremities as the patient moved about the exam room. Neurological Speech clear. Good tone. Posture erect. Balance stable; gait normal. Psychiatric Alert and oriented. Dressed in clean slacks, shirt, and coat. Maintains eye contact. Speech is soft, though clear and of normal rate and cadence; answers questions appropriately. Lab Tests Urinalysis—pending Urine culture—pending Wet prep—pending Special Tests Diagnosis Include at least three differential diagnosis Final diagnosis Evidence for final diagnosis should be documented in your Subjective and Objective exams. PLAN including education Plan: Further testing Medication Education Nonmedication treatments Follow-up Week 4 – Assignment 1 Discussion Assignment 1: Grand Rounds As a major project in this course, you will deliver a Grand Rounds presentation. The health care topic for this presentation will be decided by your course faculty based on the results of the APEA Pre-Predictor Exam in Week 1. Your presentation will consist of a patient scenario that you experienced in your clinical setting. The format of your presentation can be Microsoft PowerPoint. APA format is also expected, and references should be cited. Include references at the bottom of the slides and a final reference list on the last slide. Your goal is to: Provide a case study to go with the diagnosis. Utilize research articles or other materials to support your findings. Identify any practice barriers, issues, or problems (including cultural diversity and healthcare literacy). Discuss best practices for optimal outcomes. In addition to submitting your presentation, you will also be expected to lead a discussion throughout the week. You will want to keep the presentation interesting, professional, and focused to the topic. When the week is over, you will update, revise, and complete your presentation on the basis of student comments and instructor feedback. In Week 1, the instructor will divide the class into groups and assign you a week in which you will be expected to present your case. Some of you will present in Week 4, some will present in Week 7, and the remainder will present in Week 9. Those who are not presenting in a given week are responsible for participating in at least two presentations. For additional details, please see the Grand Rounds assignment page in the week in which you are assigned to present. Submission Details: Name your document SU_NSG6440_W4_A1_LastName_FirstInitial.doc. Week 5 -Assignment 1 Discussion Assignment 1: Discussion As a family nurse practitioner, you are working in a rural health clinic. You are evaluating a 16-year-old adolescent patient who comes in complaining of having difficulty concentrating in school. On exam, you also note that the patient is very thin and frail in appearance and is asking you for diet pills. What are some initial areas for concern? What screening tools can help lead you closer to your diagnosis? Describe 1 health promotion strategy you can discuss with the patient. Be sure to address the following in your plan of care: pharmacological and non-pharmacological (OTC) interventions, labs, follow-up, teaching, and referral/s. Your work should integrate course resources (text/s) as well as a minimum of two (2) other evidence-based guidelines and/or articles published within 3–5 years. Submission Details: Name your document SU_NSG6440_W5_A1_LastName_FirstInitial.doc. Submit by Saturday, November 4, 2017.
