Question

M.L. is a 34-year-old female nursing student who is being seen in the OB-GYN clinic for a yearly physical.

Subjective Data

Patient asks about birth control options

States she feels fine physically, no complaints at this time

Enrolled in college for nursing

Has steady boyfriend, 1-year relationship

Sexually active

Lives on campus

Nonsmoker

Exercises 3 times a week

Family hx + grandmother had uterine cancer and mother had breast cancer

Objective Data

Vital signs: T 37 P64 R 12 BP 104/64

Weight: 135

HT: 5 feet, 3 inches

Last menstrual cycle = 10 days ago

Current birth control method = condoms

Questions

1. What patient care equipment does the nurse need for this visit?
2. What personal protective equipment does the nurse or provider need to prepare for this visit?
3. Describe techniques for breast examination.
4. What other information needs to be gathered for this patient?
5. What techniques of physical assessment might be used in this visit?
6. Are there any preventative care screenings that should be done at this visit??

After answering all of the above questions, chose one of these case studies and develop a nursing diagnosis relevant to the patient discussed and a plan of care. Please make sure your "plan of care" is evidence based by listing at least one clinical trial that supports your "plan of care" For example. If you were to recommend yearly pap smears, where is the evidence that this will decrease mortality?

Answer 1

1, The patient needs pelvic examination, breast examination, pap smear, speculum examination. genetic test to reveal a genetic mutation.
2, Providers should protect themselves from body fluids and blood to avoid risk, especially when doing a pelvic examination. providers should use gloves, masks, aprons as personal protective equipment to protect themselves.
3, Breast examination:
Technique:
Inspection:
-Inspect the patient's breast with adequate privacy by visually seeing the breast and its position by observing shape, size, symmetry, texture, and colors, areas for skin thickness, dimpling, etc.
Palpation:
Palpating the breast using provider finger pads with slightly cupped position using the method of a spoke and circular movement check for soft, firm and nodular, masses, tenderness, etc. Include axilla and supraclavicular area for palpation for any lymphadenopathy. providers need to know about through anatomy, the structure of breast for performing this procedure to identify the lymph nodes.
Documentation:
Document the breast normal and abnormal findings including skin for warm, edema, erythema, sores, etc.
4, Other information needs to be gathered from this patient is about her age of menarche, birth history, using any birth control pills, history of cancer for sisters any other blood relations, any unusual bleeding and history of any chronic illness like hypertension, diabetes and substance use, etc. information about patient diet history and last gynecological examination findings provide clear patient information about any normal and abnormal findings.