Tag Archives: What observations did you make during the physical assessment?

Gynecology focused note

Patient histories are a building block of the diagnosis and treatment. By effectively interviewing patients in their care, advanced practice nurses  can piece together facts to construct a relevant history that can lead to assessment and treatment.

For this Focused Note Assignment, you will select a patient with gynecologic conditions from your clinical experience and construct a patient history, assess and diagnose the patient’s health condition(s), and justify the best treatment option(s) for the patient.

 

Note: 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 Turnitin.

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.

Resources

• Fowler, G. C. (2019). Pfenninger and Fowler’s Procedures for Primary Care(4th ed.). Elsevier.
  • Chapter 136, “Insertion and Removal of Nexplanon” (pp. 946–951)
  • Chapter 137, “Pessaries” (pp. 952–959)
  • Chapter 138, “Treatment of Noncervical Condylomata Acuminata” (pp. 960–969)
  • Chapter 139, “Vulvar Biopsy” (pp. 970–973)

Practicum Resources 

• Walden University Field Experience.Links to an external site.(n.d.-a). Field experience: College of Nursing.Links to an external site. https://academicguides.waldenu.edu/fieldexperience/son/home
• Walden University Field Experience. (n.d.-c). Student practicum resources: NP student orientation.Links to an external site.https://academicguides.waldenu.edu/StudentPracticum/NP_StudentOrientation
• Walden University Field Experience. (n.d.-b). MSN nurse practitioner practicum manual. Retrieved fromLinks to an external site.https://academicguides.waldenu.edu/fieldexperience/son/formsanddocuments
• HSoft Corporation. (n.d.). MeditrekLinks to an external site.. https://edu.meditrek.com/Default.html
  Note:Use this website to log in to Meditrek to report your clinical hours and patient encounters.
• Document: Focused SOAP Note Template (Word document)Download Focused SOAP Note Template (Word document)

Clinical Guideline Resources 

• As you review the following resources, you may want to include a topic in the search area to gather detailed information (e.g., breast cancer screening guidelines; for the CDC -zika in pregnancy, etc.).
• American College of Obstetricians and Gynecologists.Links to an external site.(n.d.). https://www.acog.org/
• American Cancer Society.Links to an external site.(n.d.). https://www.cancer.org/
• ANA Enterprise.Links to an external site.(n.d.). https://www.nursingworld.org/
• Centers for Disease Control and Prevention.Links to an external site.(n.d.). https://www.cdc.gov/
• HealthyPeople 2030. (2020).Healthy People 2030 framework.Links to an external site.
  https://www.healthypeople.gov/2020/About-Healthy-People/Development-Healthy-People-2030/Framework
• The American Association of Nurse Practitioners.Links to an external site.(2020). https://www.aanp.org/
• S. Preventive Services Task Force. (n.d.-b). Search and filter all recommendation topics.Links to an external site.https://www.uspreventiveservicestaskforce.org/uspstf/topic_search_results?topic_status=P&searchterm=

Be sure to review the Learning Resources before completing this activity.
Click the weekly resources link to access the resources.  Gynecology focused note

WEEKLY RESOURCES

To prepare:

• Use the Focused SOAP Note Template found in the Learning Resources for this week to complete this Assignment.
• Select a patient that you examined during the last three weeks. With this patient in mind, address the following in your Focused Note Template. Gynecology focused note

Assignment

• Subjective:,What details did the patient provide regarding her personal and medical history?,
• Objective:,What observations did you make during the physical assessment?,
• Assessment:,What were your differential diagnoses? ,Provide a minimum of four possible diagnoses. ,List them from highest priority to lowest priority., What was your primary diagnosis and why?,
• Plan:,What was your plan for diagnostics and primary diagnosis?, What was your plan for treatment and management including alternative therapies?, Include pharmacologic and nonpharmacologic treatments alternative therapies and follow-up parameters, as well as a rationale for this treatment and management plan.,
• Reflection notes:What would you do differently in a similar patient evaluation?