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Assignment 2: Comprehensive Well-Woman Exam

Assignment 2: Comprehensive Well-Woman Exam Assignment 2: Comprehensive Well-Woman ExamFor a wide variety of medical conditions, early detection of the problem enables timely and more effective treatment. Annual well-woman exams are among the best tools available for health care professionals to identify potential diseases and medical conditions in women.Advanced nurse practitioners can play an active role in these important visits. This role can include a physical examination as well as collection of details about such factors as nutrition habits, sexual activity, stress, and more. By participating in comprehensive well-woman exams, advanced nurse practitioners can help patients engage in preventative health.Photo Credit: Teodor Lazarev / Adobe StockFor this Assignment, you will complete your well-woman exam using a focused note format in which you will gather patient information, relevant diagnostic and treatment information and reflect on health promotion and disease prevention in light of patient factors, such as age, ethnic group, past medical history (PMH), socio-economic status, cultural background, etc.Assignment 2: Comprehensive Well-Woman ExamORDER A PLAGIARISM-FREE PAPER HERENote: All Focused Notes must be signed, and each page must be initialed by your preceptor. When you submit your Focused Notes, you should include the complete Focused Note as a Word document and pdf/images of each page that is initialed and signed by your preceptor. You must submit your Focused Notes using SAFE ASSIGN.Note: Electronic signatures are not accepted. If both files are not received by the due date, faculty will deduct points per the Walden Late Policies.Assignment 2: Comprehensive Well-Woman ExamTo prepare:Reflect on your practicum experience and select a female patient whom you have examined with the support and guidance of your Preceptor.Think about the details of the patient’s background, medical history, physical exam, labs and diagnostics, diagnosis, and treatment and management plan, and education strategies and follow-up care.What additional considerations might you think about if your patient was pregnant or just delivered?Use the “Guidelines for Comprehensive History and Physical SOAP Note” document found in this week’s Learning Resources to guide you as you complete this Assignment.Assignment:Write an 8- to 10-page Comprehensive Well-Woman Exam that addresses the following:Age, race and ethnicity, and partner status of the patientCurrent health status, including chief concern or complaint of the patientContraception method (if any)Patient history, including medical history, family medical history, gynecologic history, obstetric history, and personal social history (as appropriate to current problem)Review of systemsPhysical examLabs, tests, and other diagnosticsDifferential diagnosesManagement plan, including diagnosis, treatment, patient education, and follow-up careProvide evidence-based guidelines to support treatment plan. Note: Use your Learning Resources and evidence from scholarly sources from your personal search to support your treatment plan of care.Assignment 2: Comprehensive Well-Woman ExamReflectionReflect on some additional factors for your patient:What are the implications if your patient was pregnant or just delivered?What are implications if you have observed or know of some domestic violence? Would this change your plan of care? If so, how?Use your Learning Resources and evidence from scholarly sources from your personal search to support your reflection.Reminder: The College of Nursing requires that all papers submitted include a title page, introduction, summary, and references. The Sample Paper provided at the Walden Writing Center provides an example of those required elements (available at http://writingcenter.waldenu.edu/57.htm).Note: Your Comprehensive Well-Woman Exam Assignment must be signed by Day 7 of Week 10.By Day 7Submit your Comprehensive Well-Woman Exam Assignment by Day 7. (Note: You will submit two files, your Comprehensive Well-Woman Exam Assignment, and a Word document of pdf/images of each page that is initialed and signed by your preceptor by Day 7 of Week 10.)Assignment 2: Comprehensive Well-Woman ExamSubmission and Grading InformationTo submit your completed Assignment for review and grading, do the following:Please save your Assignment using the naming convention “WK10Assgn3+last name+first initial.(extension)” as the name.Click the Week 10 Assignment 3 Rubric to review the Grading Criteria for the Assignment.Click the Week 10 Assignment 3 link. You will also be able to “View Rubric” for grading criteria from this area.Next, from the Attach File area, click on the Browse My Computer button. Find the document you saved as “WK10Assgn3+last name+first initial.(extension)” and click Open.If applicable: From the Plagiarism Tools area, click the checkbox for I agree to submit my paper(s) to the Global Reference Database.Click on the Submit button to complete your submission. Rubric Detail Select Grid View or List View to change the rubric’s layout.ContentName: PRAC_6552_Week10_Assignment3_RubricAssignment 2: Comprehensive Well-Woman ExamGrid ViewList ViewExcellentGoodFairPoorWrite an 8- to 10-page Comprehensive Well-Woman Exam that addresses the following:• Age, race and ethnicity, and partner status of the patient• Current health status, including chief concern or complaint of the patient• Contraception method (if any)• Patient history, including medical history, family medical history, gynecologic history, obstetric history, and personal social history (as appropriate to current problem)• Review of systems• Physical exam• Labs, tests, and other diagnostics• Differential diagnoses• Management plan, including diagnosis, treatment, patient education, and follow-up care• Provide evidence-based guidelines to support treatment plan.Points Range: 40.5 (40.5%) – 45 (45%)All required points are addressed, with results that are presented fully and clearlyProvides 5 current and credible scholarly sources to support the treatment plan of care.Assignment 2: Comprehensive Well-Woman ExamPoints Range: 36 (36%) – 40 (40%)At least 8 points are addressed with results that are presented clearly.Provides at least 4 current and credible scholarly sources to support the treatment plan of care.Points Range: 31.5 (31.5%) – 35 (35%)No fewer than 7 points are addressed. One or more results presented in a manner that is vague or incomplete.Provides at least 3 current and credible scholarly sources to support the treatment plan of care.Assignment 2: Comprehensive Well-Woman ExamPoints Range: 0 (0%) – 34 (34%)Fewer than 7 points are addressed. One or more results are presented in a manner that is vague, incomplete, or inacurrate.Provides at least 2 current and credible scholarly sources to support the treatment plan of care.Reflect on the following:Reflect on some additional factors for your patient:• What are the implications if your patient was pregnant or just delivered?• What are implications if you have observed or know of some domestic violence? Would this change your plan of care? If so, how?Points Range: 36 (36%) – 40 (40%)Reflection is clearly presented, with implications that are well-formed, clear, and fully expressed.Provides at least 3 current and credible scholarly sources to support reflection.Assignment 2: Comprehensive Well-Woman ExamPoints Range: 32 (32%) – 39 (39%)Reflection is clearly presented, with implications that are clearly expressed.Provides at least 3 current and credible scholarly sources to support reflection.Points Range: 28 (28%) – 31 (31%)Reflection is presented in manner that is vague or unclear. Implications are not fully or clearly expressed.Provides at least 2 current and credible scholarly source to support reflection.Assignment 2: Comprehensive Well-Woman ExamPoints Range: 0 (0%) – 30 (30%)Reflection is presented in manner that is vague or unclear. Implications are unclear, or one or both implications not expressed.Provides at least 1 current and credible scholarly source to support reflection.Written Expression and Formatting – Paragraph Development and Organization:Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused—neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction is provided which delineates all required criteria.Points Range: 5 (5%) – 5 (5%)Paragraphs and sentences follow writing standards for flow, continuity, and clarity.A clear and comprehensive purpose statement, introduction, and conclusion is provided which delineates all required criteria.Assignment 2: Comprehensive Well-Woman ExamPoints Range: 4 (4%) – 4 (4%)Paragraphs and sentences follow writing standards for flow, continuity, and clarity 80% of the time.Purpose, introduction, and conclusion of the assignment is stated, yet is brief and not descriptive.Points Range: 3.5 (3.5%) – 3.5 (3.5%)Paragraphs and sentences follow writing standards for flow, continuity, and clarity 60–79% of the time.Purpose, introduction, and conclusion of the assignment is vague or off topic.Assignment 2: Comprehensive Well-Woman ExamPoints Range: 0 (0%) – 3 (3%)Paragraphs and sentences follow writing standards for flow, continuity, and clarity <60% of the time.no purpose statement, introduction, or conclusion was provided.written expression and formatting – english writing standards:correct grammar, mechanics, proper punctuationpoints range: 5 (5%) (5%)uses correct spelling, punctuation with no errors.points 4 (4%) (4%)contains a few (1 2) 3.5 (3.5%) (3.5%)contains several (3 4) (0%) 3 (3%)contains many (≥ 5) errors that interfere reader’s understanding.written paper follows apa format for title page, headings, font, spacing, margins, indentations, page numbers, parenthetical/in-text citations, reference list.points errors.assignment 2: comprehensive well-woman exampoints (≥5) errors. total points: 100name: prac_6552_week10_assignment3_rubric nurs 6552 prac advanced nurse practice in reproductive healthassignment: well woman examination walden university11/03/2021        week 10 assignment: examination patient information:name: m.a, age: 68years,sex: female,race: african americansubjective datacc (chief complaint): “i have some irregular vaginal bleeding”hpi:ms. arthuris a 68-year-old american post-menopausal presents bleeding, twice last months. she describes it as “heavy menstrual period lasted 2 days, each episode”. denied irritation but endorsed dryness.assignment examher at 30 years ago. lives home her husband, single-story building working smoke detectors. smokes half pack cigarettes per day, since age 20, quit smoking denies alcohol illicit drug use. has family history ofhypertension, prostate cancer, hyperlipidemia.current medications:  aspirin 81mg 1 tablet orally daily: lisinopril 20mg rosuvastatin januvia 100mg triamterene-htcz 37.5-25mg allopurinol capsule dailyallergies: known allergy. allergy to latex, animals.pmhx: hypertension, type diabetes mellitus, hyperlipidemia, uterine prolapse, gouty arthritis. had angioplasty june 2003. i hospitalizations hypertension management- 2018. influenza immunization received september 2021.covid vaccination: completed doses (pfizer). hepatitis vaccine: up date. pneumonia may 2019.soc hx: ms. arthur is married mother living children, 40, 38, 36. current tobacco reports cigarettes, 2016. enjoys walk around block husband. volunteers atthe local women’s shelter. an active choir member church—1st baptist church. uses seat belt avoids handheld phone call while driving. maintains healthy weight, diet exercise.fam both parents are deceased, father hypertensive cancer. diabetes, uterine, breast paternal grandfather died 90. grandmother congestive heart disease stroke 83. maternal 86, deceased medical condition. three biologic children alive healthy. five grandchildren well. report genetic disorders mental illnesses.ros:assignment examgeneral:  no weight loss, fever, chills, lack sleep.heent:  eyes:  wears eyeglasses, visual blurred vision, double vision yellow sclerae. ears, nose, throat:  denies hearing nasalcongestion, sore throat.skin: rash itching.cardiovascular: chest pain, pressure discomfort. palpitations, edema non murmurs.respiratory: nasal congestion, shortness breath, cough, sputum. wall clear on all lobes.gastrointestinal: anorexia, nausea, vomiting, constipation, diarrhea. abdominal pain blood stool.genitourinary: dysuria, dribbling, urgency, urine. heavy bleeding. use more than pads day. pessary prolapse. tubal ligation 1985. post coital mammogram: feb; 2020. pap smear : 10/13/2021 (negative).neurological: headaches. dizziness, syncope, paralysis, ataxia, numbness tingling extremities. change bowel bladder control.musculoskeletal: muscle discomfort, back pain. occasional joint stiffness from arthritis.hematologic: anemia, bruising. transfusion.lymphatics: enlarged nodes. splenectomy.psychiatric: depression anxiety.endocrinologic: diabetes. deniesunusual sweating, cold heat intolerance. excess thirst urination.assignment examallergies: asthma, hives, eczema. seasonal allergy.o.vitals: ht: 5’5, wt: 178 lbs.bmi: 29.6, temp: 98.4, 84, resp: 14, bp:124/82, o2: 99%physical exam: 68 yr. old americanfemale presenting clinic annual examination, complaint bleeding x times patient alert oriented x4, appropriately dressed groomed. answers questions without hesitancy makes good eye contact.heent: wnlneck: wnllungs: auscultation lung fieldsbreast: masses noted. discharge nipples.gastrointestinal: normoactive bs. mild bloatingvvbsu: bloody dischargecervix: noteduterus: +tendernessadnexa: + tendernessdiagnostics:– complete count: assesses bleeding.–  basic panel (bmp): assess electrolytes, kidneys, liver function.– pt/inr: clotting factors.– electrocardiogram: state muscles, hypertension– pelvic ultrasound: ultrasonography can be helpful measuring endometrial thickness detecting structural abnormalities uterus endometrium, such polyps, myomas, fibroids (holland et al., 2016).assignment exam– transvaginal first line diagnostic test postmenopausal women chief (faizan&muppidi, 2021).– biopsy:  abnormal findings by tvu, unsuspected eua and/or suspicious, atypical, malignant sampling require further scanning tissue diagnosis (mahdy, casey, &crotzer, 2021).a.differential diagnoses:white coat hypertension:all patients should monitored identify white-coat majority these patient’s normal said lower physician’s office. intermediate cardiovascular risk between normotensives sustained hypertensives. needs confirmation repeated office out-of-office bp measurements. if their low there hypertension-mediated organ damage (hmod), treatment not prescribed. however, they followed lifestyle modification, develop requiring (de boer, bangalore, benetos, davis, michos, muntner, rossing, zoungas, &bakris, 2017)uterine cancer: most likely prolapse smoker, obese, which places higher signs symptoms irregularvaginal tenderness, dryness points diagnosis.  endometrial cancer common gynecologic malignancy, 4th united states, after breast, lung, colorectal (schuiling, &likis, 2022).assignment exam uterine polyps: polyps focal outgrowths occur anywhere within cavity. contain variable number glands, stroma vessels, relative amounts influence appearance hysteroscopy (clark & stevenson, 2017). diagnosed imaging ultrasound (tvus), provided histological removed specimen 2017). endometrial hyperplasia: hyperplasia (eh) gynecological endocrine disease, mainly manifests infertility, even transformation. dysplasia certain tendency become cancerous, recognized precancerous lesion ec incidence 23.15–29.08%. therefore, early detection intervention eh great significance improve prognosis (zhao, hu, zhao, chen, fang ding, 2021). assignment examtreatment management postmenopausal questioned about presence bleed every visit, this practicepromotes awareness among health care providers need timely evaluation abnormal education involving them careto increase chance uterinecancer detected treated promptly appropriately(henley, miller, dowling, benard& richardson, 2018.,schuiling, 2022). management goal keeping less 130/80mmhg. might started statin prevent (scordo, 2017).health education:patient choices been shown reduce 2017).weight reduction through incorporation form physical activity daily 2022).diet modification include food rich iron calcium. like mrs. dash diet, limit sodium, avoid fried foods.assignment exam                               summary abnormal including periods sex any unexpected menopause, female over pcos, overweight 2022).cardiovascular assessed patients, especially high-risk disease. checkup advised, persons factors arthur. adopt includes exercise, eating well, aiming ideal body lessen diseases mortality reduction.  reflectiona visit provides excellent opportunity counsel maintaining minimizing risks.certain behaviors profound negative effect addressed during visit. smoking, poor associated multiple types other conditions cause significant morbidity leading causes states (the college obstetricians gynecologists. org, 2018).there long-term risks chronic those who gestational preeclampsia commodities diabetes. follow appointment:patient return week review labs monitor pressureto keep log reading, compare records.follow 6 months repeat smearassignment exam    referencesclark, t.j. h. (2017). (aub-p): what relationship, how treated? https://www-sciencedirect-com.ezp.waldenulibrary.org/science/article/pii/de i., s., a., a.m., e.d., p., s. g. hypertension: position statement association. https://care.diabetesjournals.org/content/40/9/1273faizan, u., &muppidi, v. (2021). https://www.statpearls.com/articlelibrary/viewarticle/30892.henley, s.j., j.w., n.f., benard, v.b. l.c. (2018). mortality-united 1999-2016. https://eds-p-ebscohost-com.ezp.waldenulibrary.org/eds/detail/detailholland, hodges, catron, k., bevis, berman, n., &meneses, k. (2016). using evidence impact policy. journal practitioners.https://www.npjournal.org/article/s1555-4155/mahdy, h., m., d. cancer.https://www.statpearls.com/articlelibrary/viewarticle/21102schuiling, k.d., f.e. (2022). care: introduction prenatal postpartum care. ed. jones bartlett learning.scordo, a. options:2017 guidelines. https://oce-ovid-com.ezp.waldenulibrary.org/article/00006205seagle, b-l.l., sobecki-rausch, j., strohl, a.e., shilpi, grace, &shahabi, leiomyosarcoma: national database study.https://www-sciencedirect-com.ezp.waldenulibrary.org/science/article/piithe gynecologists.org visits. https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/zhao, y., d., fang, t., m. implications clinical treatments.https://eds-p-ebscohost-com.ezp.waldenulibrary.org/eds/detail/assignment exam       

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