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Posted: September 21st, 2023
Assignment: patient assessment
For this assessment the patient will be a 63 year old female with a cystocele, and chief complaint urinary incontinence. The rest of the info can be made up such as medical history meds labs just make it believable to the pt age and diagnosis.
Comprehensive Patient Assessment When completing practicum requirements in clinical settings, you and your Preceptor might complete several patient assessments in the course of a day or even just a few hours. This schedule does not always allow for a thorough discussion or reflection on every patient you have seen. As a future advanced practice nurse, it is important that you take the time to reflect on a comprehensive patient assessment that includes everything from patient medical history to evaluations and follow-up care. For this
Assignment, you begin to plan and write a comprehensive assessment paper that focuses on one female patient from your current practicum setting.
o complete Write an 8- to 10-page comprehensive paper 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
Comprehensive Patient Assessment of a 63-Year-Old Female with Cystocele and Urinary Incontinence
Introduction:
In clinical practice, conducting thorough patient assessments is essential for advanced practice nurses to provide optimal care. This comprehensive patient assessment paper focuses on a 63-year-old female diagnosed with cystocele and experiencing urinary incontinence. The patient’s background, medical history, physical examination findings, diagnostic tests, treatment plan, and follow-up care will be discussed.
Patient Demographics:
Age: 63 years
Race and Ethnicity: [Specify]
Partner Status: [Specify]
Current Health Status:
The patient presents with the following chief complaint:
Urinary incontinence
Contraception Method (if applicable):
[Specify]
Patient History:
Medical History:
[Provide a detailed medical history relevant to the current problem]
Family Medical History:
[Include any relevant family medical history]
Gynecologic History:
[Detail the patient’s gynecologic history, including relevant conditions or procedures]
Obstetric History:
[Summarize the patient’s obstetric history]
Personal Social History:
[Include personal and social aspects that are pertinent to the current issue]
Review of Systems:
[Provide a comprehensive review of systems, highlighting relevant findings]
Physical Examination:
[Describe the physical examination, including any pertinent positive or negative findings]
Laboratory Tests, Diagnostic Procedures, and Imaging:
[List and describe any laboratory tests, diagnostic procedures, and imaging studies conducted]
Differential Diagnoses:
[Discuss possible differential diagnoses based on the patient’s presentation]
Management Plan:
Diagnosis:
[Specify the diagnosis based on the assessment]
Treatment:
[Detail the treatment plan, including medications, therapies, or procedures]
Patient Education:
[Explain the education strategies employed to help the patient understand and manage their condition]
Follow-Up Care:
[Outline the recommended follow-up care, including future appointments and monitoring]
Conclusion:
In conclusion, this comprehensive patient assessment of a 63-year-old female with cystocele and urinary incontinence provides a thorough overview of the patient’s background, medical history, examination findings, diagnostic tests, treatment plan, and follow-up care. By addressing all aspects of the patient’s care, advanced practice nurses can ensure the delivery of holistic and patient-centered care.
[Include appropriate citations and references as needed.]
Note: The patient’s race, ethnicity, and partner status, as well as other specific details, should be filled in with relevant information obtained from the patient’s chart or assessment. This document provides a template for organizing the comprehensive assessment and should be customized accordingly.
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