NURS 6512 Lab Assignment: Assessing the Genitalia and Rectum

NURS 6512 Lab Assignment: Assessing the Genitalia and Rectum

Assessing the Genitalia and Rectum

Genitourinary conditions are common encounters in nursing practice. The problems affect the patient’s health, well-being, and quality of life. Nurse practitioners utilize subjective and objective data alongside diagnostic and laboratory investigations to develop accurate diagnoses for their clients. Evidence-based guidelines inform the developed treatments that aim at promoting recovery while minimizing the risk of adverse events. Therefore, this essay analyzes R.G.’s case study. The topics analyzed include additional subjective and objective information that should be obtained from the patient if subjective and objective data support the assessment, required diagnostics, rejecting or accepting the diagnosis, and possible differential diagnoses.

Additional Subjective Information

Subjective information refers to the data that the practitioner obtains from the patient or significant others who can offer health-related information about the patient. Subjective data is a symptom as it is based on the patient’s experiences with the disease. The case study has inadequate subjective data. First, the nurse practitioner should provide adequate data about the character of the pain. This includes data such as whether the flank pain is sharp, dull, aching, or crushing. The nurse should also ascertain if the pain radiates to other body parts (Herness et al., 2020). The factors that alleviate or aggravate the urgency and dysuria should also be captured in the subjective data portion. R.G. reports that she currently uses Tylenol. Information about its effectiveness in reducing the symptoms should be obtained.

The practitioner should also obtain information about the color, smell, and amount of urine. Patients with sexually transmitted infections often report frequent urination but reduced urine volume. Abnormal urine smell might indicate urinary tract infections or sexually transmitted infections. Information about the client’s sexual and reproductive life should also be obtained. This includes her sexual habits and last menstrual period. Multiple sexual partners increase the risk of sexually transmitted infections. Information about the treatments used in the past for sexually transmitted infections should also be obtained and their effectiveness. This will guide the current treatment regime (Hudson & Mortimore, 2020). Additional information such as recent use of medications and practices such as douching should also be obtained. Douching has been associated with an increased risk of urinary tract infections.

Additional Objective Information

Objective data refers to the information that the healthcare provider obtains through methods such as inspection, auscultation, percussion, and palpation. The data is obtained through physical examination. Healthcare providers use objective data to validate subjective data. R.G.’s case study is short of objective data. First, the practitioner should assess all the body systems to rule out other possible conditions that could be attributed to the problem (Hudson & Mortimore, 2020). For example, HEENT assessment should provide information about the presence or absence of head trauma, eye drainage, jaundice, neck rigidity, jugular venous distention, nasal flaring, rhinorrhea, and postnasal drainage.

The cardiovascular system should be assessed for abnormal findings such as adventitious heart sounds, peripheral edema, and cyanosis. The respiratory system should be assessed for the presence or absence of adventitious breath sounds, chest pain, and cough. The endocrine system should also be assessed for lymphadenopathy. The client’s musculoskeletal system should be assessed for abnormal problems such as fractures, joint pain, or inflammation. The neurological system should be assessed for problems with balance, coordination, bladder, and bowel control (Herness et al., 2020). A comprehensive assessment of all the body systems is crucial to enable accurate diagnosis and ruling out potential differentials that could be contributing to R.G.’s problem.

If Subjective and Objective Information Support the Assessment

Subjective and objective information support R.G.’s assessment. As noted above, subjective data refers to the information the patient gives about their health problem while objective data refers to that obtained by the healthcare provider. The subjective data that support the assessment in the case study include her history of the presenting illness, information about her past medical history, past surgical history, current use of medication, family history, social history, and history of allergies. The objective data that supports the assessment include vital signs and abdominal assessment. Therefore, subjective and objective data support the client’s assessment.

Appropriate Diagnostics

One of the diagnostics that should be ordered besides urinalysis is the VDRL test. A VDRL test will help rule out sexually transmitted infections. Blood cultures should also be ordered to confirm the presence of an infection. The results will guide the client’s prescription of antibiotics. Ultrasound and CT scans might also be ordered should the provider suspect urinary retention, perinephric abscess, and obstructive pyelonephritis (Herness et al., 2020). Renal tract ultrasound might be required should the provider suspect ascending pyelonephritis.

Rejecting or Accepting the Current Diagnosis

I will accept the current diagnosis of urinary tract infection and reject sexually transmitted infections. R.G.’s complaints align the most with those seen in acute pyelonephritis. Pyelonephritis is a complication associated with urinary tract infection. It develops from an ascending urinary tract infection, which leads to bladder and kidney colonization by bacteria. Patients affected by pyelonephritis experience symptoms seen in R.G.’s case study. They include flank pain, fever, dysuria, increased urinary urgency, and frequency (Herness et al., 2020; Hudson & Mortimore, 2020). The absence of subjective complaints such as foul-smelling and yellow discharge rules out sexually transmitted infections.

Five Possible Differential Diagnoses

Syphilis: Syphilis is the first differential diagnosis that should be considered for this patient. Syphilis is a sexually transmitted infection spread through direct contact with infected media. Patients with syphilis often experience symptoms such as chancre, skin rash, genital or oral warts, fever, weight loss, hair loss, fatigue, lymphadenopathy, and muscle pains. R.G. might have some of the symptoms such as fever (Luo et al., 2021). However, she does not show other signs such as lymphadenopathy, chancre, and skin rashes, hence, making syphilis the least likely diagnosis.

Urethritis: Urethritis is the other differential diagnosis that should be considered for R.G. Urethritis is the inflammation of the urethra. It is a complication of a lower urinary tract infection. Most patients who are diagnosed with urethritis have sexually transmitted infections. Patients often present to the hospital with complaints that include pruritus, dysuria, and urethral discharge (Sarier & Kukul, 2019). The absence of symptoms such as urethral discharge rules out urethritis in R.G.’s case study.

Vulvovaginitis: Vulvovaginitis is the other differential diagnosis that should be considered for R.G. Vulvovaginitis is the inflammation of the vagina and vulva. Vulvovaginitis develops from causes such as genital irritation, infections, and skin diseases that include eczema. The most common symptoms seen in the affected populations include vaginal discharge and itching, pain during sex, dysuria, and spotting (Itriyeva, 2020). R.G.’s case study does not show symptoms such as vaginal irritation and spotting, which rule out vulvovaginitis.

Cervicitis: Cervicitis is the other differential to be considered in the case study. Cervicitis refers to the cervical inflammation. Causes such as sexually transmitted infections are associated with cervicitis. The affected patients often experience symptoms such as white, yellow, or gray vaginal discharge, light vaginal bleeding, pain during sex, and feelings of vaginal or vulva irritation (Shroff, 2023).

Pelvic inflammatory disease: Pelvic inflammatory disease is the other differential diagnosis that should be considered in the case study. Pelvic inflammatory disease is a complication that develops from the infection of the upper reproductive organs. The affected patients experience symptoms such as pelvic and abdominal pain, abnormal, foul-smelling vaginal discharge, pain during sex, fever, and dysuria (Curry et al., 2019; Ravel et al., 2021). R.G. reports symptoms such as pelvic pain, fever, and dysuria. However, the absence of foul-smelling vaginal discharge makes pelvic inflammatory disease the least likely cause of her problems.

Conclusion

In summary, additional subjective and objective information should be obtained in R.G.’s case study. I will accept the diagnosis of urinary tract infection and reject sexually transmitted infections based on the client’s presenting symptoms and objective data. Subjective and objective data support R.G.’s assessment. The possible differential diagnoses identified in the analysis should be ruled out by undertaking further laboratory investigations and diagnostics.

References

Curry, A., Williams, T., & Penny, M. L. (2019). Pelvic Inflammatory Disease: Diagnosis, Management, and Prevention. American Family Physician, 100(6), 357–364.

Herness, J., Buttolph, A., & Hammer, N. C. (2020). Acute Pyelonephritis in Adults: Rapid Evidence Review. 102(3).

Hudson, C., & Mortimore, G. (2020). The diagnosis and management of a patient with acute pyelonephritis. British Journal of Nursing, 29(3), 144–150. https://doi.org/10.12968/bjon.2020.29.3.144

Itriyeva, K. (2020). Evaluation of vulvovaginitis in the adolescent patient. Current Problems in Pediatric and Adolescent Health Care, 50(7), 100836. https://doi.org/10.1016/j.cppeds.2020.100836

Luo, Y., Xie, Y., & Xiao, Y. (2021). Laboratory Diagnostic Tools for Syphilis: Current Status and Future Prospects. Frontiers in Cellular and Infection Microbiology, 10. https://www.frontiersin.org/articles/10.3389/fcimb.2020.574806

Ravel, J., Moreno, I., & Simón, C. (2021). Bacterial vaginosis and its association with infertility, endometritis, and pelvic inflammatory disease. American Journal of Obstetrics and Gynecology, 224(3), 251–257. https://doi.org/10.1016/j.ajog.2020.10.019

Sarier, M., & Kukul, E. (2019). Classification of non-gonococcal urethritis: A review. International Urology and Nephrology, 51(6), 901–907. https://doi.org/10.1007/s11255-019-02140-2

Shroff, S. (2023). Infectious Vaginitis, Cervicitis, and Pelvic Inflammatory Disease. Medical Clinics, 107(2), 299–315.

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