see attachment
In order to earn credit, please be sure to use evidence based, peer-reviewed journals that have been published within the past 3-5 years in addition to your text and course materials in your case study. Avoid website documents as they are not peer reviewed. Please remember not to use websites or articles designed for patient use. As an advanced practice nurse, you will need to learn where to find appropriate research and resources that are designed for medical personnel and not patients.
Table 1
Hillary is a 63-year-old woman G7P7 all uncomplicated NSVDs, complains of inadvertently urinating on herself whenever she coughs, sneezes, or heartily laughs. It has been happening intermittently
Testing or Management
Define and describe
Candidates eligible for this include:
Special consideration
Example: Urinalysis and Urine culture
Lab tests to assess and rule out UTI
Performed on all patients who are having urinary symptoms especially, dysuria, urinary frequency, urgency, and urinary incontinence
n/a
Urodynamics
Pelvic Floor Muscle Therapy
Percutaneous Tibia Nerve Stimulator
Pessary Therapy
Surgical management
Type of incontinence
Definition and Example
How to assess Treatment/ Management
Stress Incontinence
Urge Incontinence
Nocturnal Incontinence
Transient Incontinence
since the birth of her last 3 children, but it now happens so often that she must wear a sanitary pad, and she is afraid there can be an odor at times. She now also feels “something at the entrance.” Upon physical exam, you note that there is an organ about 1cm covering at the 12 o’clock of her vaginal entrance. She asks you what, if anything, can be done to alleviate this that does not have to entail having surgery.
Write a brief SOAP note regarding this patient. Make sure to include your answers to these questions in your SOAP note.
1. Subjective: a. What other relevant questions should you ask regarding the HPI? b. What other medical history questions should you ask? c. What other social history questions should you ask? d. What other family history questions should you ask?
2. Objective: a. Write a detailed focused physical assessment on this patient. b. Explain what test(s) you will order and perform, and discuss your rationale for
ordering and performing each test. 3. Assessment/ Diagnosis:
a. What is your presumptive diagnosis? Why? b. Any other diagnosis or differential diagnosis you would like to add? c. What type of incontinence is this patient experiencing?
4. Plan: a. How will you manage this patient? What treatment or medication would you prescribe
and why? b. Explain treatment/management guidelines including any possible side effects and/or
consideration management of the diagnosis. c. What patient education is important to include for this patient? (Consider including
pharmacological, supplements, and non pharmacological recommendations and education)
d. What is the follow-up plan of care?
,
SOAP NOTE FORMAT
Subjective
CC:
HPI:
Medications:
Allergies:
LMP:
Gyn/OB history:
PMH:
Chronic Illness/ Major trauma:
Family Hx:
Social Hx:
ROS
– List the body systems and provide answers
– (Don’t forget to include Gyn ROS)
– You can include questions here that you’d like to ask the patient
Objective Data
General- provide findings
VS
List body systems- provide findings
– (Don’t forget Gyn System)
– (You can include answers here to questions posed in the prompt)
Include POCT (Point of Care testing) not labs that you will send to the laboratoryAssessment/
DiagnosisInclude the ICD10 code
DDX
Plan
Diagnostic tests
Lab Tests
Treatment
Medication
Referrals
Education
Health Maintenance
Follow up
Prompt Questions
(You can include answers here that is asked in the prompt)