Week 7

Case Study 1:

R.B. 95-year-old, white male, currently living in a skilled nursing facility (SNF)

Chief complaint: “My urine is really red.”

HPI: On Wednesday (2 days ago) the patient was brought to your clinic by his son and complained that his urine appeared to be bright red in color. You ordered labs, urinalysis, culture, and sensitivity, and the results are below.

Allergies: Penicillin: Hives

Medications: Tamsulosin 0.4 mcg, 2 capsules daily, Aspirin 325 mg daily, Atorvastatin 10 mg 1 tablet daily, Donepezil 10 mg 1 tablet PO QHS, Metoprolol 25 mg 0.5 mg tablet every 12 hours, Acetaminophen 500 mg 1 tablet BID

Code status: DNR  Regular diet, pureed texture, honey-thickened liquids

Vitals: BP 122/70, HR 66, Temp 98.0 F, Resp 18, Pulse ox 98%

PMH: Cognitive communication deficit, pneumonitis due to inhalation of food and vomit, dysphagia, R-side hemiplegia and hemiparesis past ischemic CVA, moderate vascular dementia, malignant neoplasm of prostate, new-onset atrial fibrillation (12/2019), DVT on left lower extremity, gross hematuria

Labs:

RBC                         3.53 (L)

Hemoglobin           10.2 (L)

Microscopic Analysis, Urine, straight cath

Component:

WBC UA                                      42 (H)              (0-5/ HPF)

RBC, UA                                      >900 (H)  (0-5/HPF)

Epithelial cells, urine                2                    (0-4 /HPF)

Hyaline casts, UA                     0                    (0-2 /LPF)

Urinalysis

Color  Red

Appearance (Urine)       Clear

Ketones, UA                  Trace

Specific gravity             1.020                   (1.005-1.025)

Blood, UA                      Large

PH, Urine                       7.0        (5.0-8.0)

Leukocytes                    Small

Nitrites                          Positive

C&S results were not available yet.

Assignment: Assessing, Diagnosing, and Treating Abdominal, Urological, and Gynecological Disorders

Photo Credit: Teodor Lazarev / Adobe Stock

Accurate history taking of abdominal, urological, and gynecological complaints is essential for completing an assessment of the older adult. For this Assignment, as you examine this week’s patient case study, consider how you might evaluate and treat older adult patients who present with health concerns related to the abdominal, urological, or gynecological systems.

To prepare:

• Review the case study provided by your Instructor.
• Reflect on the patient’s symptoms and aspects of disorders that may be present.
• Consider how you might assess, perform diagnostic tests, and recommend medications to treat patients presenting with the symptoms in the case.
• Access the Focused SOAP Note Template in this week’s Resources.

The Assignment:

Complete the Focused SOAP Note Template provided for the patient in the case study. Be sure to address the following:

• Subjective: What was the patient’s subjective complaint? What details did the patient provide regarding their history of present illness and personal and medical history? Include a list of prescription and over-the-counter drugs the patient is currently taking. Compare this list to the American Geriatrics Society Beers Criteria®, and consider alternative drugs if appropriate. Provide a review of systems.
• Objective: What observations did you note from the physical assessment? What were the lab, imaging, or functional assessments results?
• Assessment: Provide a minimum of three differential diagnoses. List them from top priority to least priority. Compare the diagnostic criteria for each, and explain what rules each differential in or out. Explain you critical thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case.
• Plan: Provide a detailed treatment plan for the patient that addresses each diagnosis, as applicable. Include documentation of diagnostic studies that will be obtained, referrals to other health-care providers, therapeutic interventions, education, disposition of the patient, caregiver support, and any planned follow-up visits. Provide a discussion of health promotion and disease prevention for the patient, taking into consideration patient factors, past medical history (PMH), and other risk factors. Finally, include a reflection statement on the case that describes insights or lessons learned.Kennedy-Malone, L., Martin-Plank, L., & Duffy, E. (2019). Abdominal disorders. In Advanced practice nursing in the care of older adults (2nd ed., pp. 225–279). F. A. Davis.

Kennedy-Malone, L., Martin-Plank, L., & Duffy, E. (2019). Urological and gynecological disorders. In Advanced practice nursing in the care of older adults (2nd ed., pp. 280–304). F. A. Davis.

Demarest, L. (2019). Gotta go right now: What’s overactive bladder? Nursing Made Incredibly Easy!, 17(4), 11–14. https://doi.org/10.1097/01.NME.0000559586.35631.37

Jackson, P., & Vigiola, C. M. (2018). Intestinal obstruction: Evaluation and management. American Family Physician, 98(6), 362–367.

Shian, B., & Larson, S. T. (2018). Abdominal wall pain: Clinical evaluation, differential diagnosis, and treatment. American Family Physician, 98(7), 429–436.

Document: Focused SOAP Note Template (Word Document)

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