Lab Assignment: Assessing the Genitalia and Rectum

Lab Assignment: Assessing the Genitalia and Rectum

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

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 cl