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NURS 6512 Assignment 1: Lab Assignment: Assessing the Genitalia and Rectum

NURS 6512 Assignment 1: Lab Assignment: Assessing the Genitalia and Rectum

Walden University NURS 6512 Assignment 1: Lab Assignment: Assessing the Genitalia and Rectum-Step-By-Step Guide

 

This guide will demonstrate how to complete the Walden University  NURS 6512 Assignment 1: Lab Assignment: Assessing the Genitalia and Rectum assignment based on general principles of academic writing. Here, we will show you the A, B, Cs of completing an academic paper, irrespective of the instructions. After guiding you through what to do, the guide will leave one or two sample essays at the end to highlight the various sections discussed below.

 

How to Research and Prepare for NURS 6512 Assignment 1: Lab Assignment: Assessing the Genitalia and Rectum

 

Whether one passes or fails an academic assignment such as the Walden University  NURS 6512 Assignment 1: Lab Assignment: Assessing the Genitalia and Rectum depends on the preparation done beforehand. The first thing to do once you receive an assignment is to quickly skim through the requirements. Once that is done, start going through the instructions one by one to clearly understand what the instructor wants. The most important thing here is to understand the required format—whether it is APA, MLA, Chicago, etc.

 

After understanding the requirements of the paper, the next phase is to gather relevant materials. The first place to start the research process is the weekly resources. Go through the resources provided in the instructions to determine which ones fit the assignment. After reviewing the provided resources, use the university library to search for additional resources. After gathering sufficient and necessary resources, you are now ready to start drafting your paper.

 

How to Write the Introduction for  NURS 6512 Assignment 1: Lab Assignment: Assessing the Genitalia and Rectum

 

The introduction for the Walden University  NURS 6512 Assignment 1: Lab Assignment: Assessing the Genitalia and Rectum is where you tell the instructor what your paper will encompass. In three to four statements, highlight the important points that will form the basis of your paper. Here, you can include statistics to show the importance of the topic you will be discussing. At the end of the introduction, write a clear purpose statement outlining what exactly will be contained in the paper. This statement will start with “The purpose of this paper…” and then proceed to outline the various sections of the instructions.

 

How to Write the Body for  NURS 6512 Assignment 1: Lab Assignment: Assessing the Genitalia and Rectum 

 

After the introduction, move into the main part of the  NURS 6512 Assignment 1: Lab Assignment: Assessing the Genitalia and Rectum assignment, which is the body. Given that the paper you will be writing is not experimental, the way you organize the headings and subheadings of your paper is critically important. In some cases, you might have to use more subheadings to properly organize the assignment. The organization will depend on the rubric provided. Carefully examine the rubric, as it will contain all the detailed requirements of the assignment. Sometimes, the rubric will have information that the normal instructions lack.

 

Another important factor to consider at this point is how to do citations. In-text citations are fundamental as they support the arguments and points you make in the paper. At this point, the resources gathered at the beginning will come in handy. Integrating the ideas of the authors with your own will ensure that you produce a comprehensive paper. Also, follow the given citation format. In most cases, APA 7 is the preferred format for nursing assignments.

 

How to Write the Conclusion for  NURS 6512 Assignment 1: Lab Assignment: Assessing the Genitalia and Rectum

 

After completing the main sections, write the conclusion of your paper. The conclusion is a summary of the main points you made in your paper. However, you need to rewrite the points and not simply copy and paste them. By restating the points from each subheading, you will provide a nuanced overview of the assignment to the reader.

 

How to Format the References List for  NURS 6512 Assignment 1: Lab Assignment: Assessing the Genitalia and Rectum

 

The very last part of your paper involves listing the sources used in your paper. These sources should be listed in alphabetical order and double-spaced. Additionally, use a hanging indent for each source that appears in this list. Lastly, only the sources cited within the body of the paper should appear here.

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NURS 6512 Assignment 1: Lab Assignment: Assessing the Genitalia and Rectum

Background

The client, T.S., is a 32-year-old woman who presented with dysuria, frequency, and urgency to the clinic. She denies using anything to ease the discomfort. The client reports that these symptoms have persisted for the past year. She discloses having a new partner for the last three months and being sexually active. This paper analyzes the subjective portion, the objective portion of the note, how subjective and objective information supports the assessment, appropriate diagnostics, and rejection/acceptance of the current diagnosis.

The Subjective Portion Analysis and Additional Information

         The presented subjective data include dysuria, frequency, and urgency, which have persisted for the past year. These symptoms characterize urinary tract infection (UTI). However, additional information is required to confirm the client’s condition. First, the client’s history of STDs or previous UTI occurrences should be included in subjective data. Furthermore, the subjective portion should capture information regarding using protection during sexual intercourse and experiencing pain or discomfort during intercourse. Finally, informations about any discharge or blood spots should be documented to guide inappropriate diagnosis and treatment.

The Objective Portion Analysis and Additional Information

         The objective data indicates mild tenderness to palpation in the client’s suprapubic region, no adnexal tenderness, a normal-sized uterus and adnexa, no vaginal discharge, and a normal cervix. However, additional objective data is needed to assist in the client’s diagnosis and treatment. First, the presence or absence of blood in the urine should be included in the objective portion. Furthermore, the healthcare professional should evaluate the color and smell of the client’s urine. Finally, details of chills/fever should be documented.

Does the Subjective and Objective Information Support Client’s Assessment

The client’s assessment is urinary tract infection (UTI). UTI in women is mainly characterized by fever, a persistent

Assignment 1 Lab Assignment Assessing the Genitalia and Rectum
Assignment 1 Lab Assignment Assessing the Genitalia and Rectum

and strong urge to urinate, chills, a burning sensation when urinating, foul-smelling and cloudy urine, and pelvic pain (Gupta et al., 2017). The client reports these symptoms, including dysuria, frequency, and urgency, persisted for the past year. Therefore, the presented subjective data supports the client’s assessment of urinary tract infection. Additionally, objective data, including suprapubic or pelvic pain on palpation, cloudy or foul-smelling urine, bloody urine, or bleeding of the inflamed bladder wall, characterize UTIs in women (Flores-Mireles et al., 2019). The client’s object data indicates mild tenderness to palpation in the suprapubic area, supporting her assessment of urinary tract infection.

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Appropriate Diagnostics

In addition to subjective and objective data, diagnostics would be needed to make the client’s diagnosis. The first diagnostic is a urine culture . The presence of uropathogen in urine cultures is a definitive UTI diagnostic test. Additionally, a urinalysis or urine dipstick should be performed to assess pyuria. The presence of pyuria in this client indicates that she has UTI. According to Beahm et al. (2017), pyuria in urine dipstick or a significant volume of uropathogen in a urine culture indicates UTI. STD tests should also be performed. Positive results for STDs indicate sexually transmitted UTIs. A CT scan should also be used to identify pyelonephritis or abscesses. The presence of pyelonephritis or abscesses indicates UTI. Finally, ultrasonography should be done due to its extreme sensitivity in detecting obstruction, tumors, abscesses, and cysts.

Acceptance of the Current Diagnosis

The client’s current diagnosis is urinary tract infection (UTI), mainly characterized by fever, a persistent and strong urge to urinate, chills, burning sensation when urinating, foul-smelling and cloudy urine, and pelvic pain. The client reports dysuria, frequency, and urgency, which have persisted for the past year. These symptoms align with her current diagnosis, UTI; hence it should be accepted. Additionally, the UTI is characterized by objective data, including hematuria, fever/chills, oliguria, foul-smelling urine, suprapubic region, or abdominal pain. The client’s objective data indicates mild tenderness to palpation in the client’s suprapubic area. Therefore, the client’s current diagnosis should be accepted.

Overall, the client is a 32-year-old woman who presented to the clinic with dysuria, frequency, and urgency, which have persisted for the past year. Additional subjective data, including the client’s history of STDs or previous UTI incidents, information regarding using protection during sexual intercourse and experiencing pain or discomfort during intercourse, and details about any discharge or blood spots are needed to assist the healthcare provider in making an appropriate diagnosis for this client. The objective data indicates mild tenderness to palpation in the client’s suprapubic region, no adnexal tenderness, a normal-sized uterus and adnexa, no vaginal discharge, and a normal cervix. However, additional objective data, including the presence or absence of blood in the urine, color, smell of their urine, and details of chills/fever, are needed to assist in the client’s diagnosis. The client’s assessment is urinary tract infection (UTI), mainly characterized by fever, a persistent and strong urge to urinate, chills, burning sensation when urinating, foul-smelling and cloudy urine, and pelvic pain. These symptoms are reported in the client’s objective and subjective data. Therefore, her assessment is supported by subjective and objective data and should be accepted as the most appropriate diagnosis for this client.

References

Beahm, N. P., Nicolle, L. E., Bursey, A., Smyth, D. J., & Tsuyuki, R. T. (2017). The assessment and management of urinary tract infections in adults: guidelines for pharmacists. Canadian Pharmacists Journal/Revue des Pharmaciens du Canada150(5), 298-305. Doi: 10.1177/1715163517723036

Flores-Mireles, A., Hreha, T. N., & Hunstad, D. A. (2019). Pathophysiology, treatment, and prevention of catheter-associated urinary tract infection. Topics in spinal cord injury rehabilitation, 25(3), 228-240. DOI: 10.1310/sci2503-228.

Gupta, K., Grigoryan, L., & Trautner, B. (2017). Urinary tract infection. Annals of internal medicine, 167(7), 49-64. https://doi.org/10.7326/AITC201710030

Assessment of the genitalia and rectum is vital in depicting genitourinary and gastrointestinal abnormalities respectively. A rectal examination is necessary to complete an abdominal exam. Meanwhile, assessment of the genitalia is usually sensitive and must be done in the presence of a chaperone. In the subsequent paragraphs, potential history, physical exam, and differential diagnosis shall be explored based on a case scenario of T.S. a 32-year-old woman who presents with dysuria, frequency, and urgency for two days. She is sexually active and has had a new partner for the past three months.

Subjective

A triad of urgency, frequency, and dysuria characterizes a pathology that is most likely in the urinary tract. Consequently, it is essential to inquire about associated symptoms such as hematuria, fever, and malaise. Association with malaise and fever is common in urinary tract infections. Similarly, it is important to inquire about the presence of any abnormal vaginal discharge, and burning sensation during urination since she is sexually active and a sexually transmitted infection might be the cause of her symptoms. Likewise, changes in the smell and color of the urine must be elicited as well as associated suprapubic pain. Related to sexually transmitted infections, it is crucial to inquire about the number of sexual partners if similar symptoms have manifested in her partner or the use of protection during intercourse (Garcia & Wray, 2022).

Similarly, her last menstrual period must be known to determine if pregnant as this will impact the management (Bono et al., 2022). Additionally, a history of medication use, alcohol, smoking, and use of illicit drugs must be elicited. A history of contact with an individual with a chronic cough or TB prior to the occurrence of the previous symptoms must be elicited as urogenital TB may present similarly. Finally, it is crucial to inquire about any history of trauma or recent urethral catheterization as these are common risk factors for urinary tract infections.

Objective

The vital signs are mandatory in this patient as it is a pelvic exam. In the general exam, the mental and nutrition status of the patient must be noted. Additionally, a complete abdominal exam must be conducted as the patient has flank pain and suprapubic tenderness. Palpation of the abdomen for any masses and percussion of the flank for costovertebral angle tenderness must be done (Bono et al., 2022). Similarly, complete respiratory and cardiovascular exams must be conducted as a routine during the assessment of any patient. Finally, a digital rectal examination must be performed to exclude associated rectal abnormalities.

Assessment

In addition to urinalysis, STI, and pap smear testing, a complete blood count and urine culture must be conducted as the patient presents with signs of infection. Similarly, a pregnancy test must be conducted as this may complicate urinary tract infections. Additionally, she has no appetite and therefore a random blood sugar must be done to exclude hypoglycemia. Similarly, urea, creatinine, and electrolyte must be conducted to check the renal function as the patient has flank pain. Finally, Inflammatory markers such as ESR and CRP as well as blood cultures must be done as the patient has flank pain which may indicate pyelonephritis (Bono et al., 2022). Imaging tests are not necessary for the diagnosis of lower UTI. However, the patient has flank pain, and therefore, a CT scan of the abdomen and pelvis with or without IV contrast as well as an ultrasound of the kidneys and bladder must be done to identify any pathologies and outline the architecture of the kidney and bladder (Belyayeva & Jeong, 2022)

The possible diagnoses include a urinary tract infection and a sexually-transmitted infection. Urinary tract infections refer to the infection of the bladder, urethra, ureters, or kidneys (Bono et al., 2022). UTIs are more common in women, a consequence of a short urethra and proximity of the anal and genital regions (Bono et al., 2022). A triad of frequency, dysuria, and urgency collectively defines the irritative lower urinary tract symptoms (Bono et al., 2022). Similarly, suprapubic tenderness is a key feature of lower urinary tract infections. However, the patient is also feverish and has flank pain which also denotes the potential for involvement of the upper urinary tract (Bono et al., 2022). T.S is also sexually active, a risk factor for urinary tract infection.

A sexually transmitted infection is another possible diagnosis. T.S is sexually active and she has had her new partner for the last three months which is a key risk factor for this condition (Garcia & Wray, 2022). Most STIs present with suprapubic pain. Most STIs are asymptomatic and if symptomatic manifests with urethral discharge, vaginal discharge, pruritus, and pain (Garcia & Wray, 2022). T.S was negative for the aforementioned features.

Other differential diagnoses include pyelonephritis, interstitial cystitis, and urethritis due to an STI. Pyelonephritis is of the renal pelvis and parenchyma (Belyayeva & Jeong, 2022). It is usually a complication of ascending bacterial infection of the bladder and manifests principally with frequency, dysuria, urgency, fever, malaise, flank pain, and suprapubic pain (Belyayeva & Jeong, 2022). Interstitial cystitis is a chronic noninfectious idiopathic cystitis associated with recurrent suprapubic pain (Daniels et al., 2018). It presents with urgency, frequency, suprapubic discomfort, and pain relieved by voiding. T.S has some of these features although the gradual onset of symptomatology and a duration of more than six weeks is required for the diagnosis of this condition (Daniels et al., 2018). Finally, urethritis secondary to an STI may present in females with only frequency, urgency, and dysuria with minimal or no vaginal discharge (Young et al., 2022).

Conclusion

Assessment of the genitalia and rectum is sensitive and may help identify abnormalities of the rectum and genitourinary tract. Most abnormalities of the genitourinary system particularly UTIs and STIs can be diagnosed clinically. Consequently, a comprehensive history and physical examination are mandatory. Most UTIs are common in females. Pregnancy must always be excluded in a patient presenting with features suggestive of a UTI.

References

Belyayeva, M., & Jeong, J. M. (2022). Acute Pyelonephritis. https://pubmed.ncbi.nlm.nih.gov/30137822/

Bono, M. J., Leslie, S. W., & Reygaert, W. C. (2022). Urinary Tract Infection. https://pubmed.ncbi.nlm.nih.gov/29261874/

Daniels, A. M., Schulte, A. R., & Herndon, C. M. (2018). Interstitial cystitis: An update on the disease process and treatment. Journal of Pain & Palliative Care Pharmacotherapy32(1), 49–58. https://doi.org/10.1080/15360288.2018.1476433

Garcia, M. R., & Wray, A. A. (2022). Sexually Transmitted Infections. https://pubmed.ncbi.nlm.nih.gov/32809643/

Young, A., Toncar, A., & Wray, A. A. (2022). Urethritis. https://pubmed.ncbi.nlm.nih.gov/30725967/

Rubric

NURS_6512_Week_10_Assignment1_Rubric
NURS_6512_Week_10_Assignment1_Rubric
Criteria Ratings Pts

With regard to the SOAP note case study provided and using evidence-based resources from your search, answer the following questions and support your answers using current evidence from the literature:·   Analyze the subjective portion of the note. List additional information that should be included in the documentation.

12 to >9.0 pts

Excellent
The response clearly, accurately, and thoroughly analyzes the subjective portion of the SOAP note and lists detailed additional information to be included in the documentation.

9 to >6.0 pts

Good
The response accurately analyzes the subjective portion of the SOAP note and lists additional information to be included in the documentation.

6 to >3.0 pts

Fair
The response vaguely analyzes the subjective portion of the SOAP note and vaguely and/or inaccurately lists additional information to be included in the documentation.

3 to >0 pts

Poor
The response inaccurately analyzes the subjective portion of the SOAP note, with inaccurate and/or missing additional information included in the documentation.
12 pts

·   Analyze the objective portion of the note. List additional information that should be included in the documentation.

12 to >9.0 pts

Excellent
The response clearly, accurately, and thoroughly analyzes the objective portion of the SOAP note and lists detailed additional information to be included in the documentation.

9 to >6.0 pts

Good
The response accurately analyzes the objective portion of the SOAP note and lists additional information to be included in the documentation.

6 to >3.0 pts

Fair
The response vaguely analyzes the objective portion of the SOAP note and vaguely and/or inaccurately lists additional information to be included in the documentation.

3 to >0 pts

Poor
The response inaccurately analyzes the objective portion of the SOAP note, with inaccurate and/or missing additional information included in the documentation.
12 pts

·  Is the assessment supported by the subjective and objective information? Why or why not?

16 to >13.0 pts

Excellent
The response clearly and accurately identifies whether or not the assessment is supported by the subjective and/or objective information, with a thorough and detailed explanation.

13 to >10.0 pts

Good
The response accurately identifies whether or not the assessment is supported by the subjective and/or objective information, with a clear explanation.

10 to >7.0 pts

Fair
The response vaguely identifies whether or not the assessment is supported by the subjective and/or objective information, with a vague explanation.

7 to >0 pts

Poor
The response inaccurately identifies whether or not the assessment is supported by the subjective and/or objective information, with an inaccurate or missing explanation.
16 pts

·   What diagnostic tests would be appropriate for this case, and how would the results be used to make a diagnosis?

20 to >17.0 pts

Excellent
The response thoroughly and accurately describes appropriate diagnostic tests for the case and explains clearly, thoroughly, and accurately how the test results would be used to make a diagnosis.

17 to >14.0 pts

Good
The response accurately describes appropriate diagnostic tests for the case and explains how the test results would be used to make a diagnosis.

14 to >11.0 pts

Fair
The response vaguely and/or with some inaccuracy describes appropriate diagnostic tests for the case and vaguely and/or with some inaccuracy explains how the test results would be used to make a diagnosis.

11 to >0 pts

Poor
The response inaccurately describes appropriate diagnostic tests for the case, with an inaccurate or missing explanation of how the test results would be used to make a diagnosis.
20 pts

·   Would you reject or accept the current diagnosis? Why or why not?·   Identify three possible conditions that may be considered as a differenial diagnosis for this patient. Explain your reasoning using at least three different references from current evidence-based literature.

25 to >22.0 pts

Excellent
The response states clearly whether to accept or reject the current diagnosis, with a thorough, accurate, and detailed explanation of sound reasoning. The response clearly, thoroughly, and accurately identifies three conditions as a differential diagnosis, with reasoning that is explained clearly, accurately, and thoroughly using three or more different references from current evidence-based literature.

22 to >19.0 pts

Good
The response states whether to accept or reject the current diagnosis, with an accurate explanation of sound reasoning. The response accurately identifies three conditions as a differential diagnosis, with reasoning that is explained using three different references from current evidence-based literature.

19 to >16.0 pts

Fair
The response states whether to accept or reject the current diagnosis, with a vague explanation of the reasoning. The response identifies two to three conditions as a differential diagnosis, with reasoning that is explained vaguely and/or inaccurately using three or fewer references from current evidence-based literature.

16 to >0 pts

Poor
The response inaccurately states or is missing a statement of whether to accept or reject the current diagnosis, with an explanation that is inaccurate and/or missing. The response identifies three or fewer conditions as a differential diagnosis, with reasoning that is missing or explained inaccurately using two or fewer references from current evidence-based literature.
25 pts

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 are provided that delineate all required criteria.

5 to >4.0 pts

Excellent
Paragraphs and sentences follow writing standards for flow, continuity, and clarity. A clear and comprehensive purpose statement, introduction, and conclusion are provided that delineate all required criteria.

4 to >3.0 pts

Good
Paragraphs and sentences follow writing standards for flow, continuity, and clarity 80% of the time. Purpose, introduction, and conclusion of the assignment are stated, yet are brief and not descriptive.

3 to >2.0 pts

Fair
Paragraphs and sentences follow writing standards for flow, continuity, and clarity 60%–79% of the time. Purpose, introduction, and conclusion of the assignment are vague or off topic.

2 to >0 pts

Poor
Paragraphs and sentences follow writing standards for flow, continuity, and clarity < 60% of the time. No purpose statement, introduction, or conclusion were provided.
5 pts

Written Expression and Formatting – English writing standards: Correct grammar, mechanics, and proper punctuation

5 to >4.0 pts

Excellent
Uses correct grammar, spelling, and punctuation with no errors.

4 to >3.0 pts

Good
Contains a few (1 or 2) grammar, spelling, and punctuation errors.

3 to >2.0 pts

Fair
Contains several (3 or 4) grammar, spelling, and punctuation errors.

2 to >0 pts

Poor
Contains many (≥ 5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding.
5 pts

Written Expression and Formatting – The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, running heads, parenthetical/in-text citations, and reference list.

5 to >4.0 pts

Excellent
Uses correct APA format with no errors.

4 to >3.0 pts

Good
Contains a few (1 or 2) APA format errors.

3 to >2.0 pts

Fair
Contains several (3 or 4) APA format errors.

2 to >0 pts

Poor
Contains many (≥ 5) APA format errors.
5 pts
Total Points: 100