Lab Assignment: Assessing the Genitalia and Rectum/NURS 6512

Lab Assignment: Assessing the Genitalia and Rectum/NURS 6512

Lab Assignment: Assessing the Genitalia and Rectum/NURS 6512

Assessing Genitalia and Rectum
Analysis of Subjective Portion
The subjective section of the data contains data that was obtained from the client. Subjective assessment provides subjective data that represents the perceptions of the client towards health and health problems. The subjective assessment provides the information about the point of view of the patient including concerns, perceptions, and feelings. The subjective assessment that was performed on the client is inadequate. Additional subjective data should be obtained from the client. One of them is asking the client about the characteristics of the bump. The client should be asked to describe the factors that she thinks to contribute to the growth or restricted spread of the bump. An example would be asking her about her experiences when she applies skin ointments on the bump. The other question that the client should be asked is about whether there is pain or tenderness in the regions surrounding the bump. The information will aid in the determination of whether the bump is attributed to an infection or not and whether it is benign or not. The client should also be asked to describe the nature of boundaries or contours of the bump (Feeney & Everett, 2019). This includes the determination of whether the bump has regular or irregular boundaries.

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It is also important to ask the patient about her experiences when passing stool. The nurse should determine whether pain is experienced during voiding or passing stool. The patient should also be asked about her sexual orientation and sexual practices. The information about sexuality could aid in the determination of causes of the bump such as infection or trauma. It is however worth noting that questions related to sexual function and gender identity are highly sensitive. It is therefore important that the provider ask the patient questions related to this area in a non-judgmental approach. The patient should be encouraged to describe her unpleasant experiences related to sexual function and identity since they might point towards a probable cause for the health problem. There is also the need to ask the client for occasional symptoms such as nausea, fever, chills, malaise, and vomiting. The information is important since it aids in ruling out aspects such as fistulas. The client should also be asked to assess her perceived severity of the health problem. The client should be asked to rate on a scale of 0-10 about the nature of her symptoms and feelings towards the health problem (Feeney & Everett, 2019). In this case, a score of 0 will represent no effect of symptoms on the client while 10 will represent severe effect of the symptoms on the patient.
The client should also be asked about any history of bump in the rectum or genitalia regions. The information will aid in the determination of possibilities of symptom recurrence. The healthcare provider should also obtain information about the menstrual history of the client. Menstrual history that should be obtained includes duration of menses and amount of menstrual loss. It is hypothesized that hormonal changes during menstrual cycles, puberty, and pregnancy could result in pimples or bumps in the genitalia and the rectum. There is also the high risk of similar bumps during stressful events. The client should therefore be asked about her recent encounters to determine whether they have been stressful or not. Eliciting information on whether there exists a family history for the complaint is also necessary (Feeney & Everett, 2019). The existence of a family member with similar problem could point towards genetic influence and increased risk of benign tumors.
Analysis of the Objective Portion
Objective assessment was undertaken in the objective portion. Objective assessment provides data based on the findings of the healthcare provider. They provide additional cues on the health problem of the patient. Objective data is also used to validate subjective data. The objective portion should have included additional objective data. One of them is comprehensive assessment of the skin. The healthcare provider should have performed a comprehensive assessment of the skin from head to toe. The assessment should have focused on a number of aspects. They include the general skin pigmentation, changes in skin color, symmetry and size of moles and freckles, temperature, moisture, edema, bruising, lesions, nails, and distribution of hair (Howatson-Jones, Standing & Roberts, 2015). Comprehensive assessment of the skin could have provided additional information on the involvement of the integumentary system.
The objective portion should have also included the assessment of the anal region to determine the presence of abnormal masses or skin color. The assessment of the anal region could have provided insights into the nature of spread of the health problem. The healthcare provider could have also included a detailed assessment of the genitalia. This includes the skin color, swelling or lesions in clitoris, inflammation or stricture on urethral opening, inflammation or lesions in the vaginal opening, and palpation of the vagina for Bartholin’s glands, swelling, tenderness, and discharge (Mochtar et al., 2017). Therefore, the acquisition of the above subjective data would aid in the development of an accurate diagnosis for the patient’s health problem and development of a treatment plan.
Support for the Assessment
Objective and subjective data supported the assessment of the patient in the case study. As shown earlier, the patient provides subjective data. It mainly focuses on the patient’s perception of the health problem. Subjective data provides insights into the onset of symptoms, severity, relieving factors, and influence on patient’s sense of wellbeing. It also seeks to explore the patient’s understanding of the health problem alongside the perceived benefits of the treatment. The healthcare provider on the other hand develops objective data from the assessment. The data is obtained using methods such as inspection, palpation, percussion, and auscultation. The objective data is used to validate the patient’s health problem and diagnosis. The case study utilized both subjective information from the patient and objective data from the physical examination that the healthcare provider performed. Therefore, the use of these types of data enhanced the accuracy of the diagnosis that was reached and the adopted treatment approach to the health problem.
Diagnostic Investigations
Often, the treatment of genital ulcers depends largely on the clinical presentation of its associated symptoms. However, diagnostic tests might be utilized to promote accurate diagnosis of the health problem and the use of targeted treatment. A number of tests are recommended for the client in the case study. They include blood test for syphilis and HIV/AIDs, antibody testing or direct fluorescent testing for Treponema pallidum, and culture test for herpes simplex virus or Haemophilus ducreyi. The results of the above diagnostic tests will be used to make the treatment decisions in a number of ways. Firstly, the presence of any disease causing organism in the tests will be important in guiding the most appropriate and effective treatment. It will also inform the use of treatment methods such as combined therapy for treatment to achieve optimum outcomes of care (Roett, 2020). It will also enable the adoption of treatment decisions that are associated with minimal adverse effects to the patient.
Rejecting or Accepting Current Diagnosis
I will agree with the current diagnosis of chancre. Chancre is characterized by a single as well as painless well-demarcated ulcer. The ulcer also has indurated border with clean base. The fact that the bump has been there for some time without the patient knowing increases its possible diagnosis. The three differential diagnoses for the patient’s health problem are lymphogranuloma venereum, granuloma inguinale, and Molluscum contagiosum. Molluscum contagiosum is a viral infection that causes skin rashes or bumps in any part of the body. It arises from engaging in sexual activity or contact with infective body fluids. The bumps are swollen, small in size, painless, and fresh colored. Lymphogranuloma venereum is characterized by shallow, small, and painless rectal or genital papule. The papule might ulcerate in the site of infection. They can remain undetected in the site of infection. Bacterial infections can however complicate this type of infection leading to genital elephantiasis. Granuloma inguinale is another infection that has the feature of persistent, beefy, painless papules or ulcers. The ulcers might be necrotic, hypertrophic, or sclerotic. The patients affected by this infection often experience scarring alongside other complains such as intermittent arthritis and recurrent genital or oral ulcers (Noda et al., 2016). Therefore, there is an increased need to undertake additional investigations to rule out the specific cause of the client’s health problem.

References
Feeney, Á., & Everett, S. (2019). Understanding Supervision and Assessment in Nursing. SAGE Publications Limited.
Howatson-Jones, L., Standing, M., & Roberts, S. (2015). Patient assessment and care planning in nursing. Learning Matters.
Mochtar, M., Murasmita, A., Irawanto, M. E., & Elistasari, E. Y. (2017). Genital Ulcers in Women with HIV Proposed Revision on Management Algoritm. American Journal of Life Sciences, 5(3), 93-96.
Noda, A. A., Blanco, O., Correa, C., Pérez, L., Kourí, V., & Rodríguez, I. (2016). Etiology of genital ulcer disease in male patients attending a sexually transmitted diseases clinic: First assessment in Cuba. Sexually transmitted diseases, 43(8), 494-497.
Roett, M. A. (2020). Genital Ulcers: Differential Diagnosis and Management. American Family Physician, 101(6), 355-361.

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Lab Assignment: 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
Assess health conditions based on a head-to-toe physical examination

Review your resources for this week. There is no discussion this week.

Your first assignment is an analysis of a SOAP note. Do not write a SOAP note. Instead, review what is given and focus on answering the questions given to you.
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 three 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.

Case for Assignment

For this assignment, you will analyze an Episodic note case study that describes abnormal findings in patients seen in a clinical setting. You will consider what history should be collected from the patients, as well as which physical exams and diagnostic tests should be conducted. You will also formulate a differential diagnosis with several possible conditions.

Review the following Episodic note case study:

Subjective:
• CC: “I have bumps on my bottom that I want to have checked out.”
• HPI: AB, a 21-year-old WF college student reports to your clinic with external
bumps on her genital area. She states the bumps are painless and feel rough.
She states she is sexually active and has had more than one partner during the
past year. Her initial sexual contact occurred at age 18. She reports no abnormal
vaginal discharge. She is unsure how long the bumps have been there but
noticed them about a week ago. Her last Pap smear exam was 3 years ago, and
no dysplasia was found; the exam results were normal. She reports one sexually
transmitted infection (chlamydia) about 2 years ago. She completed the
treatment for chlamydia as prescribed.
• PMH: Asthma
• Medications: Symbicort 160/4.5mcg
• Allergies: NKDA
• FH: No hx of breast or cervical cancer, Father hx HTN, Mother hx HTN, GERD
• Social: Denies tobacco use; occasional etoh, married, 3 children (1 girl, 2 boys)
Objective:
• VS: Temp 98.6; BP 120/86; RR 16; P 92; HT 5’10”; WT 169lbs
• Heart: RRR, no murmurs
• Lungs: CTA, chest wall symmetrical
• Genital: Normal female hair pattern distribution; no masses or swelling. Urethral
meatus intact without erythema or discharge. Perineum intact. Vaginal mucosa
pink and moist with rugae present, pos for firm, round, small, painless ulcer noted
on external labia
• Abd: soft, normoactive bowel sounds, neg rebound, neg murphy’s, negMcBurney
• Diagnostics: HSV specimen obtained
Assessment:
• Chancre
PLAN: This section is not required for the assignments in this course