Assessing The Genitalia And Rectum Essay
Assessing The Genitalia And Rectum Essay
Running Head: ASSESSING THE GENITALIA AND RECTUM1Health Assessment SOAP Note: Assessing the Genitalia and Rectum
ASSESSING THE GENITALIA AND RECTUM2Analysis ofthe subjective portionOne of the first things to consider is whether there are bumps anywhere else on the body or only the genitalia and whether the bumps are painful and rough.Testing such as the digital rectal examination is necessary to improve health outcomes, but there is a need for best practice to achieve this (Sabbagh et al., 2014). The bumps may be present at all the times, or come and go. If there is anything that appears to aggravate the bumps like soap or clothing then this should be noted, it is also necessary to assess whether there are things that make the bumps disappearPast Medical History (PMH): Asthma, ChlamydiaAny past history of other STIsAny skin conditionsAge of Asthma diagnosis andcomplications if anyMedication previously prescribed for ChlamydiaPast Surgical History (PSH): Such as c-sections and femalesurgeries,Medications:Are there acute medicationsSexual/Reproductive HistorySexual orientation History of sexually transmitted infectionsInfertilityType of contraception usedAbortions Number of children Assessing The Genitalia And Rectum Essay
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ASSESSING THE GENITALIA AND RECTUM3Analysisofthe objective portionThe patient has no other major healthproblemsheis well spokengroomed, dressed,clean and makes eye contact. Assess the throat for any infections, lesions and cold sores. For the neck, there is focus on the range of motion, cervical and clavicular lymph nodes, position, thyroid examination and mobility of the trachea(Dains, Baumann & Scheibel, 2016).For the genital/rectal, thereis an inspectionof the perineum for nits, lesions areas of swelling or tenderness ovarian enlargement, masses,hair distribution, and tenderness. She had a Pap smear threeyears ago and was toldit was normal, but there has been no information on the mammography.Assessmentand diagnosisSyphilisThetransmission of some bacterial infections likesyphilis requires human-to-human contact, and Chlamydia, which may be contractedas an STI, mayspread to the child duringchildbirth.Thesubjective and objective data supportthe diagnosis, but focus on thefalse-positive serologic test for syphilis isnecessaryto make accurateassessments. Pelvic examination is also carried out to identify and rule out diseases and infections (Westhoff, Jones &Guiahi, 2011).Herpes Simplex Type-2Herpes simplex virus-2 (HSV-2) mainly infects the genitalia, and the viruses at times affect the skin and the oral cavity or the central nervous system. There are recurrent genital symptoms, and oneof the man challenges is preventing recurrences of the infections. Herpes is highly contagious, and there are no indications that the patienthas suffered recurrent infections.Assessing The Genitalia And Rectum Essay
ASSESSING THE GENITALIA AND RECTUM4The subjective data for herpes simplex is “tenderness, pain, paresthesia, or mild burning at the infected site before the onsetof the lesions” (Ballet al., 2015).Herpes Progenitalis with asymptomatic ChlamydiaWhile the diagnosis is unlike, the patientas a history of Chlamydia and her sexual history influences the risk of more infections. Chlamydial genital infectionsmay beasymptomatic,andlaboratory evaluation is necessary to diagnosethe diseaseand rule out thediseases and differ infections.Acute Contact DermatitisReactivedermatitis and contact dermatitis are skin disorders that affect the genital tract,andsuch disorders are sexually transmitted. Acute contact dermatitis causes inflammation and is mostlycharacterizedby lesions. Diagnostics will help rule out acute contact dermatitis and other dermatologic disorder.Insect BitesInsect bites are unlikely to be the main cause of the bump. Assessing The Genitalia And Rectum Essay However,determining her activities beforethe bump appearing such as being in places with many insects is useful to determine the risks. Insect bites can cause various skin disorders and infection of the dermis and subcutaneous tissue.PlanAssessing the skin and documenting this is the first step to determine the interventions that are most appropriate, besides this intervention, there are laboratory tests to determine the patient health status. The medications and treatment m depend onwhathas been identifiedand what has been ruled out. Theexpected outcome is that the patient will not experience a recurrenceof Chlamydia infections or pain and the bump will be dealtwith. Theplanning and
ASSESSING THE GENITALIA AND RECTUM5implementation focuson administeringthe medication asrequired, emphasizing theneed for regular checkups and discussing concerns about the diagnosis.ReferencesBall, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015). Seidel’s guide to physical examination(8th ed.). St. Louis, MO: Elsevier Mosby.Dains, J. E., Baumann, L. C., & Scheibel, P. (2016). Advanced health assessment and clinical diagnosis in primary care(5th ed.). St. Louis, MO: Elsevier Mosby.Sabbagh, C., Mauvis, F., Vecten, A., Ainseba, N., Cosse, C., Diouf, M., &Regimbeau, J. M. (2014). What is the best position for analyzing the lower and middle rectum and sphincter function in a digital rectal examination? A randomized, controlled study in men. Digestive and Liver Disease, 46(12), 1082–1085.doi:10.1016/j.dld.2014.08.045Westhoff, C. L., Jones, H. E., &Guiahi, M. (2011). Do new guidelines and technology make the routine pelvic examination obsolete? Journal of Women’s Health, 20(1), 5–10 Assessing The Genitalia And Rectum Essay
Introduction to Evidence-Based Physical Examination Essay
Male genitalia includes the external, internal, and glandular accessory structures that function to produce and transport viable sperm for reproduction. As part of a well visit, the clinician assesses for normal functioning of male genitourinary and reproductive systems, health maintenance, and health promotion needs. During an episodic visit, the clinician focuses on specific complaints or concerns.
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Pros and cons to essay on Overview of Nursing Health Assessment
Deep palpation is performed to assess for massesand internal organs. Percussion is used to elicit tenderness or sounds that may provideclues to underlying problems. When percussing directly over suspected areas of tenderness, monitor the patient for signs of discomfort.Percussion requires skill and practice. The method of percussion is described as follows: Press the distal part of the middle finger of your non-dominant hand firmly on the body part. Keep the rest of your hand off the body surface. Flex the wrist, but notthe foreman, of your dominant hand. Using the middle finger of your dominant hand, tap quickly and directlyover the point where your other middle finger contacts the patient’s skin, keeping the fingers perpendicular.Listen to the sounds produced. The purpose of obtaining a health history is to provide you with a description of your patient’s symptoms andhow they developed. A complete history will serve as a guide to help identify potential or underlying illnessesor disease states. In addition to obtaining data about the patient’s physical status, you will obtain informationabout many other factors that impact your patient’s physical status including spiritual needs, culturalidiosyncrasies, and functional living status Assessing The Genitalia And Rectum Essay
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Citations about essay on Genital Examination Training: Assessing the Effectiveness of an Integrated Female and Male Teaching Programme
Some criteria for evaluating simulation learning programmes have been developed. A supportive learner-centred milieu, with access to expert tutors, and the subsequent ability for any programme to ‘map onto clinical experience’ are considered important features to demonstrate [Alnassar SA, Almuhaya RA, 2012]. The combined use of teaching modalities has been shown to be effective. For example, the addition of a standardised patient to a simulation model and use of electronic feedback [Dabson AM, Magin PJ, 2014], the use of standardised patients to teach genital examination prior to using the mechanical simulation, and the use of an online learning module viewed immediately prior to a simulated class session [Alnassar SA, Almuhaya RA, 2012]. With increasing numbers of medical students in successive classes and student feedback suggesting a learning/teaching deficit, a need was identified at the University of Otago, Wellington, New Zealand to improve first-time genital examination teaching at an appropriate time in the curriculum for all students, especially those inclined to be reticent about such examination practice.Assessing The Genitalia And Rectum Essay
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Conclusion to Techniques of Physical Assessment Essay
Evidently, creating and maintaining appropriate documentation is a legal, ethical and professional requirement for nurses. Health records provide evidence about the type of assessment and care patients receive. They are also important clinical tools, enabling continuity of care and effective decision-making.
Baseline data that is collected after the health history and before the complete head to toe examination includes a general survey of the client. The general survey includes the patient’s weight, height, body build, posture, gait, obvious signs of distress, level of hygiene and grooming, skin integrity, vital signs, oxygen saturation, and the patient’s actual age compared and contrasted to the age that the patient actually appears like. For example, does the patient appear to be older than their actual age? Does the patient appear to be younger than their actual age?Assessing The Genitalia And Rectum Essay
Nurses prepare and position clients for physical examinations. Nurses provide privacy, explain and reinforce the procedures to the client and insure that the client is as comfortable as possible during the physical examination.
As with all other aspects of nursing care, all data and information that is collected with the health history and the physical examination are documented according to the particular facility’s policies and procedures. Some facilities use special forms for this data and information.
Registered nurses, advanced practice nurses such as nurse practitioners, and doctors typically do the complete head to toe physical assessment and examination and document all of these details in the patient’s medical record; however, licensed practical nurses review these details and compare this baseline physical examination data and information to the current patient status as they are providing ongoing care. They also report and document all their significant physical examination results to the supervising registered nurse and/or the patient’s health care provider.Assessing The Genitalia And Rectum Essay
The four basic methods or techniques that are used for physical assessment are inspection, palpation, percussion and auscultation. Inspection is a visual examination of the patient; palpation is done when the person doing the assessment places their fingers on the body to determine things like swelling, masses, and areas of pain. Palpation can include light and deep palpation. Deep palpation is cautiously done after light palpation when necessary because the client’s responses to deep palpation may include their tightening of the abdominal muscles, for example, which will make the light palpation less effective for this assessment, particularly if an area of pain or tenderness has been palpated.
Percussion is tapping the patient’s bodily surfaces and hearing the resulting sounds to determine the presence of things like air and solid masses affecting internal organs. The sounds that are heard with percussion are resonance which is a hollow sound, flatness which is typically hear over solid things like bone, hyper resonance which is a loud booming sound, and tympany which is a drum type sound.Assessing The Genitalia And Rectum Essay
Lastly, auscultation is listening to an area of the body using a stethoscope. For example, bowel sounds, lung sounds and heart sounds are auscultated with a stethoscope. The sounds that are heard with auscultation are classified and described according to their duration, pitch, intensity and quality. For example, the duration of a breath sound can be described in terms of seconds of duration or it can be described as having a longer duration of inspiration than expiration. The intensity can be describe as loud or soft and quiet; the pitch is described as a high pitched sound to a dull and low pitched sound.Assessing The Genitalia And Rectum Essay