American Sentinel N522PE Module Six: Mental Health Assessment & Male and Female Urinary and Reproductive Systems

Permalink:

Discussion 6

This week you have studied mental health (psychological); urinary and reproductive systems of the male and female in advanced physical assessment. While this is a diverse set of advanced physical assessment skills where do you place your greatest level of confidence and what areas need more development. Of these areas of advanced physical assessment where to you struggle in your nursing practice most when providing patient-centered education? American Sentinel N522PE Module Six: Mental Health Assessment & Male and Female Urinary and Reproductive Systems

Please cite sources for additional knowledge, skill development, or professional development related to reproductive health and provide additional “clinical pearls” learned this week. In other words, please include primary sources and/or reliable electronic sources to support your arguments.

Remember to respond to at least two of your peers. Please refer to the Course Syllabus for Discussion Participation Guidelines & Grading Criteria.

Sample Solution for Discussion 6

Assessments this week are areas I feel more comfortable with especially with the mental health aspect. I have worked in long term and skilled nursing facilities for my entire career so mental health is always present. I not only see various dementia’s that occur but have always had a high percentage of patients with multiple mental health diagnoses of bipolar, depression, and schizophrenia. I have used the mini-mental state exam (MMSE) which was then switched to the brief interview for mental status (BIMS) in nursing homes. I always felt the MMSE was a better tool and didn’t understand the change until I just found an article stating the intellectual property rights were transferred to the Psychological Assessment Resources which is why it is no longer easy to get. Studies have shown The Montreal Cognitive Assessment to be just as effective in determining mild cognitive loss in individuals (Tsoi et al., 2015). I have used the geriatric depression screening tool and the Patient Health Questionnaire (PHQ-9). I became certified in psych about ten years ago since I was so involved with it. I did find a site that provided a lot of information on taking history related to mental health issues located at if anyone wants to look at it.

My familiarity with the urinary system and problems associated with it are mostly based on the geriatric adult so I need to increase my knowledge base on the rest of the population but the physical assessment portion stays the same so I feel confident in this area regarding my skills. I have to say when I look for sources outside of our books on male and female reproductive assessments one can find educational but distracting assessments and procedures. I ended up learning how to insert an intrauterine device (IUD) which was really interesting but not necessary.

References:

370 words

Well done. Describe how to document the female genitalia starting with inspection.

12 words

Documentation of the female genitalia will include the visual inspection and the internal exam to include both normal and abnormal. The inspection portion will include details of the external genitalia to consist of inflammation present or not, the presence or lack of presence of ulcers, swelling, or masses. Any abnormalities observed should be described and should include if the area was palpated with a description of how the mass or nodule felt. The internal exam documentation will include a description of the vaginal mucosa color and if any discharge is observed or not. Documentation for the cervix color, if it is parous or nulligravid, and if any type of discharge is observed. If there is discharge the characteristics should be documented also. The characteristics of the uterus position if midline should be documented along with the size and if any adnexal masses are palpated. Documentation of pap smear being performed, if one was done. The last portion would be if there was a mass felt within the rectal vault, the color of stool, and if any fecal blood is observed. There should also be included any signs or complaints of tenderness or pain during the exam.

Reference:
Bickley, L. S., Szilagyi, P. G., Hoffman, R. M., & Soriano, R. P. (2016). Bates guide to physical examination and history taking (Thirteenth, North American ed.). Wolters Kluwer,.

224 words

Interesting post Darcy. I also work in long term care so I agree that mental health is always a huge presence in what we do. It’s interesting to me how some co-workers want to know descriptively what a resident’s cognition level is like and some only want to know their BIMS and nothing more. I have only been in LTC for 6 months so I still have a lot to learn in that respect. I came from the emergency department where I was a sexual assault nurse, so the chapter on female genitalia was something I was more familiar with. I appreciate you listing that website for mental health issues. I’ll be sure to check that out! Thanks for your detailed post. American Sentinel N522PE Module Six: Mental Health Assessment & Male and Female Urinary and Reproductive Systems
Kristy

123 words

Assignment 4

Assignment Instructions:

For this 4-5 pages assignment, you will conduct a focused health history and physical assessment based upon your Practice Experience work in Shadow Health. Particularly, you will complete a focused assessment on Esther, an elderly patient who is complaining of abdominal discomfort. Please submit your summary documentation in MS Word. Use the submission parameters and rubric below to guide you in completion of this written assignment.

Submission Parameters:

For this written assignment, please use the following guidelines and criteria. Also, please refer to the rubric for point allocation and assignment expectations. The expected length of the paper is approximately 4-5 pages, which does not include the cover page and reference page(s).

Introduction (including purpose statement)
Focus of the assessment
1. Describe the focus of this particular assessment on the patient complaining of abdominal discomfort.
Subjective Component
1. Describe the ROS, PMH, and other relevant data in this section.
Objective Component
1. Describe the physical examination findings including techniques of examination
Documented evidence to support clinical reasoning
1. Describe the list of differential diagnoses
Plan of care
1. Describe the plan of care individualized to findings, life-span stage of development with culturally specific considerations for each focused area of assessment.
Conclusion
References (use primary and/or reliable electronic sources)

In regards to APA format, please use the following as a guide:

Include a cover page and running head (this is not part of the 4-5 pages limit)
Include transitions in your paper (i.e. headings or subheadings)
Use in-text references throughout the paper
Use double space, 12 point Times New Roman fonta
Apply appropriate spelling, grammar, and organization
Include a reference list (this is not part of the 4-5 pages limit)
Attempt to use primary sources only. That said, you may cite reliable electronic sources (i.e. NCSBN, AANP)

Rubric

Competency	20	18	16	0	Points Earned
Focus of the Assessment is identified with Special Considerations including Documented Focused Health History	Documentation clearly shows student has completed a focused assessment with identified special considerations including a well-documented focused health history. American Sentinel N522PE Module Six: Mental Health Assessment & Male and Female Urinary and Reproductive Systems	Documentation supports the student has completed the focused assessment with minimal identification of special concerns. The focused health history is documented.	Documentation supports the student has completed the focused assessment without identification of special concerns. The focused health history is documented and lacks depth and specificity of weekly topic.	Documentation supports the student attempted to complete the focused assessment without identification of special concerns. The focused health history is briefly documented and lacks depth and specificity of weekly topic.	/20
	20	18	16	0
Documented Physical Examination Findings including Techniques of Examination	Documentation clearly shows student has completed the physical examination and accurately describes the techniques of examination for the week.	Documentation supports the student has completed the physical examination and describes the techniques of examination for the week.	Documentation supports student completed some of the physical examination for the focused assessment of the week. Documentation is accurate but lacks depth.	No evidence that the student is applying read concepts of advanced focused physical assessment. Documentation lacks depth and may lack coherence for understandability of tasks completed in this week.	/20
	20	18	16	0
Documented Evidence to Support Clinical Reasoning with External Course Resources	Discourse clearly shows the student has studied the topic and has given thought to the focused assessed topic and documentation for the week.	Discourse supports the student has studied the topic and has given thought to the focused assessment topic and documentation for the week.	Discourse supports student studied some of the topic for the focused assessment topic this week. Discourse is accurate but lacks depth.	No evidence that that student has read or studied the topic. Discourse lacks depth. May be presented in a rambling manner. Content is inaccurate &/or is unclear.	/20
	20	18	16	0
Individualized Plan of Care Based Upon Clinical Findings	Accurately presents an individualized plan of care based upon clinical findings.	Presents an individualized plan of care based upon clinical findings. Some minor omissions are noted.	Presents a plan of care that is not individualized based upon the clinical findings.	A plan of care is not presented or the plan of care presented lacks demonstration of competency or is irrelevant to the clinical findings.	/20
	5	4	3	0
Developmentally and Culturally Specific	Accurately documents a developmentally and culturally specific assessment and plan of care for the selected patient.	Documents a developmentally and culturally specific assessment and plan of care.	Presents a developmentally and culturally specific assessment or plan of care and one or both are not based upon the selected patient.	A developmentally and culturally specific assessment and plan of care are not presented or based upon the selected patient’s findings.	/5
	5	4	3	0
Demonstration of Compliance with Ethical and Legal Standards of Professional Nursing Practice	Compliance with the ethical and legal standards of professional nursing practice is explicitly stated in the documentation of the focused physical assessment.	Compliance with the ethical and legal standards of professional nursing practice is stated in the documentation.	Compliance with the ethical and legal standards of professional nursing practice is briefly implied in the documentation of the focused physical assessment or inaccuracies are evidenced in the written assessment.	Compliance with the ethical and legal standards of professional nursing practice is not included in the documentation of the focused physical assessment. American Sentinel N522PE Module Six: Mental Health Assessment & Male and Female Urinary and Reproductive Systems	/5
	10	9	8	0
Grammar, Spelling, and Punctuation APA Format	APA Format, grammar, punctuation and spelling is accurate with errors.	APA Format, grammar, punctuation and spelling is accurate with less than two types of errors.	APA Format, grammar, punctuation and spelling is accurate with five or fewer types of errors.	APA Format, grammar, punctuation and spelling is accurate with more than five types of errors.	/10
COMMENTS:				TOTAL:	/100

Competency

18 16 0
Points Earned

Focus of the Assessment is identified with Special Considerations including Documented Focused Health History

Documentation clearly shows student has completed a focused assessment with identified special considerations including a well-documented focused health history. American Sentinel N522PE Module Six: Mental Health Assessment & Male and Female Urinary and Reproductive Systems

Documentation supports the student has completed the focused assessment with minimal identification of special concerns. The focused health history is documented.

Documentation supports the student has completed the focused assessment without identification of special concerns. The focused health history is documented and lacks depth and specificity of weekly topic.

Documentation supports the student attempted to complete the focused assessment without identification of special concerns. The focused health history is briefly documented and lacks depth and specificity of weekly topic.

/20

Documented Physical Examination Findings including Techniques of Examination

Documentation clearly shows student has completed the physical examination and accurately describes the techniques of examination for the week.

Documentation supports the student has completed the physical examination and describes the techniques of examination for the week.

Documentation supports student completed some of the physical examination for the focused assessment of the week. Documentation is accurate but lacks depth.

No evidence that the student is applying read concepts of advanced focused physical assessment. Documentation lacks depth and may lack coherence for understandability of tasks completed in this week.

/20

Documented Evidence to Support Clinical Reasoning with External Course Resources

Discourse clearly shows the student has studied the topic and has given thought to the focused assessed topic and documentation for the week.

Discourse supports the student has studied the topic and has given thought to the focused assessment topic and documentation for the week.

Discourse supports student studied some of the topic for the focused assessment topic this week. Discourse is accurate but lacks depth.

No evidence that that student has read or studied the topic.
Discourse lacks depth. May be presented in a rambling manner.
Content is inaccurate &/or is unclear. American Sentinel N522PE Module Six: Mental Health Assessment & Male and Female Urinary and Reproductive Systems

/20

Individualized Plan of Care Based Upon Clinical Findings

Accurately presents an individualized plan of care based upon clinical findings.

Presents an individualized plan of care based upon clinical findings. Some minor omissions are noted.

Presents a plan of care that is not individualized based upon the clinical findings.

A plan of care is not presented or the plan of care presented lacks demonstration of competency or is irrelevant to the clinical findings.

/20

Developmentally and Culturally Specific

Accurately documents a developmentally and culturally specific assessment and plan of care for the selected patient.

Documents a developmentally and culturally specific assessment and plan of care.

Presents a developmentally and culturally specific assessment or plan of care and one or both are not based upon the selected patient.

A developmentally and culturally specific assessment and plan of care are not presented or based upon the selected patient’s findings.

Demonstration of Compliance with Ethical and Legal Standards of Professional Nursing Practice

Compliance with the ethical and legal standards of professional nursing practice is explicitly stated in the documentation of the focused physical assessment.

Compliance with the ethical and legal standards of professional nursing practice is stated in the documentation.

Compliance with the ethical and legal standards of professional nursing practice is briefly implied in the documentation of the focused physical assessment or inaccuracies are evidenced in the written assessment.

Compliance with the ethical and legal standards of professional nursing practice is not included in the documentation of the focused physical assessment.

Grammar, Spelling, and Punctuation APA Format

APA Format, grammar, punctuation and spelling is accurate with errors.

APA Format, grammar, punctuation and spelling is accurate with less than two types of errors.

APA Format, grammar, punctuation and spelling is accurate with five or fewer types of errors.

APA Format, grammar, punctuation and spelling is accurate with more than five types of errors.

/10

COMMENTS:

TOTAL:

/100 American Sentinel N522PE Module Six: Mental Health Assessment & Male and Female Urinary and Reproductive Systems

American Sentinel N522PE Module Six: Mental Health Assessment & Male and Female Urinary and Reproductive Systems