NURS 6551 Week 9 Practicum Experience Journal Essay - Walden University

NURS 6551 Week 9 Practicum Experience Journal Essay - Walden University

NURS 6551 Week 9 Discussion – After identifying potential health risks for pregnant patients, providers often recommend behavior changes in lifestyle choices such as drug use, alcohol consumption, dietary habits, and environmental exposures. Even with provider recommendations and patient education programs, some patients still struggle to adhere to recommended lifestyle changes during pregnancy, posing health risks for both the mother and child. In your role as the provider, you must be able to recognize signs of nonadherence to recommended lifestyle changes because not all patients will be forthcoming with the struggles they may be experiencing. NURS 6551 Week 9 Practicum Experience Journal Essay - Walden University. Management plans are only successful if patients’ individual needs are recognized and met, so provider-patient collaboration is essential for mitigating nonadherence issues. For this Discussion, consider implications of nonadherence to recommended lifestyle changes and potential management strategies for pregnant patients. NURS 6551 Week 9 Practicum Experience Journal Essay - Walden University

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To prepare FOR NURS 6551 Week 9 Discussion:

  • Review the “During Pregnancy” article in this week’s Learning Resources.
  • Think about the health promotion topic that you selected for the Week 8 Discussion (i.e., smoking, drinking, taking drugs, eating habits, and caring for pets).
  • With the topic you selected in mind, consider early signs and symptoms that might indicate a patient’s nonadherence to recommended lifestyle changes during pregnancy. Think about the impact of nonadherence on the fetus and the patient.Reflect on treatment and management strategies for patients presenting with signs and symptoms of nonadherence to recommended lifestyle changes. NURS 6551 Week 9 Practicum Experience Journal Essay - Walden University

 By Day 3 OF NURS 6551 Week 9 Discussion

Post  at least 250 words ( no introduction or conclusion)

  •  an explanation of signs and symptoms that might indicate a pregnant patient’s nonadherence to recommended lifestyle changes related to the topic you selected. ( smoking in pregnancy is the topic we did last week)
  • Explain the impact of nonadherence to these lifestyle recommendations on the fetus and the patient.
  • Then, explain treatment and management strategies for patients presenting with signs and symptoms resulting from their nonadherence.

Abnormal Uterine Bleeding

Society for Reproductive Endocrinology and Infertility (SREI, 2012) described abnormal uterine bleeding as bleeding that differs in quality and quantity from normal menstrual bleeding, such as women spotting or bleeding between the women’s menstrual periods; bleeding after sex; bleeding heavier or last more days than normal; and bleeding post menopause. According to SREI (2012), factors that can cause abnormal bleeding include structural abnormalities of the reproductive system, such as uterine polyps, fibroids, and adenomyosis. NURS 6551 Week 9 Practicum Experience Journal Essay - Walden University. Furthermore, SREI (2012) explained that vaginal, uterine or cervical lesions, miscarriage, ectopic pregnancy, endometritis, adhesions in the endometrium, and use of an intrauterine device (IUD) can also cause abnormal bleeding. Johns Hopkins Medicine (2016) specified that early recognition of abnormal bleeding, and seeing a health care provider immediately for appropriate diagnosis and treatment increase the chance of successful treatment. Therefore, the author will focus on a single patient comprehensive evaluation, which includes the patient’s personal/health history; physical examination; laboratory/diagnostic tests; diagnosis; treatment/management plan; education strategies; and follow-up care. Comment by DeAllen B Millender: Good introduction. NURS 6551 Week 9 Practicum Experience Journal Essay - Walden University

General Patient Information

Age: 41-year-old

Race/Ethnicity: Hispanic American

Partner Status: Married Comment by DeAllen B Millender: This information is not in APA format.

Current Health Status

Chief Complaint: “I have heavy, prolonged menstrual bleeding with severe cramping for the past one year”. NURS 6551 Week 9 Practicum Experience Journal Essay - Walden University

History of Present Illness (HPI): RG is a 41-year-old Hispanic American female who presented to the clinic with complaint of heavy prolonged menstrual bleeding with severe cramping for the past one year. Patient reported sharp pelvic pain during menstruation, bleeding between periods, pain with intercourse, blood clots during periods. Abdominal pain/pressure and bloating. NURS 6551 Week 9 Practicum Experience Journal Essay - Walden University. Patient suggested that these symptoms started after her second caesarean section surgery one year ago. Patient also reported that she takes over-the counter medication, such as ibuprofen to relieve the pain. she also suggested that she uses heating pad on her abdomen/pelvic for pain relief, and she stated that she soaks in a warm sitz bath to ease pelvic pain and cramping. Patient also reported fatigue and weakness. Patient further stated that she decided to see an obstetrician and gynecologist (OB/GYN) because the heavy prolonged bleeding with severe menstrual cramp interfere with her regular activities. Patient denied nausea, vomiting, diarrhea, fever, and chills. NURS 6551 Week 9 Practicum Experience Journal Essay - Walden University

Timing/Onset: Patient said one year ago.

Location: The location of the problem as stated by the patient is pelvic/uterus/vaginal.

Duration: 5 to7 days during periods for the past one year.

Quality/Characteristic: Patient reported heavy prolonged menstrual pain; severe, sharp lower abdominal/pelvic cramping/pain, and blood clots during periods.

Aggravating Factors: Monthly periods as stated by the patient.

Relieving/Alleviating Factors: Patient stated that ibuprofen pain medication, heating pad, and/or warm sitz bath help the pain/cramping. NURS 6551 Week 9 Practicum Experience Journal Essay - Walden University

Severity: The severity of the pain/cramping on a pain scale is 10/10 reported by the patient.

Treatments/Therapies: Patient stated that she had not undergone any treatment for the reported problems.

Last Menstrual Period: The last menstrual period reported by patient was 7/5/2016.

Sexual Activity Status: Patient reported being sexually active.

Barrier Prevention: Patient stated she uses natural barrier methods.

Sexual Preference: Patient sexual preference is monogamous/heterogeneous relationship.

Satisfaction with Sexual Activity: Patient reported that she is sexually satisfied with her partner.

Contraception Method: Patient denied using any contraception method.

Patient History

Past medical History (PMH): Anemia and C-section. Patient was delivered full term through vaginal delivery without complications. The birth weight was 8 pounds 10 oz. NURS 6551 Week 9 Practicum Experience Journal Essay - Walden University

Psychological/Mental Health: Patient denied depression, mood swings, anxiety, or mental health problem.

Medications: RG reported that she takes over the counter Motrin 200-400 mg orally every 4-6 hours as needed for pain and cramping.

Allergies: Patient reported no known allergies (NKA).

Past Surgical/Hospitalization History: Patient reported history of C-section twice, and she was hospitalized for 3 days post the C-sections.

Preventive Screening: Patient reported that she had flu shot on 11/20/2015; last mammogram was 2/12/2015 and mammogram was normal; Pap smear was on 2/20/2015, which was also normal; patient also reported that she was up to date with her childhood immunization, but denied pneumococcal vaccination.

Family History: Both father and mother have history of diabetes mellitus type 2 and hypertension. Both parents are still living, and two siblings are still living and well.

Gynecological History: Patient is multipara with 2 pregnancy resulting in two viable offsprings. Patient had her first child at the age of 33 years. Menarche at age 13; periods last between 5 to 7 days. Patient reported heavy prolonged menstrual bleeding with severe cramping; sharp pelvic pain during menstruation; and bleeding between periods for the past one year. Denied vaginal discharge or sexually transmitted infection/disease. NURS 6551 Week 9 Practicum Experience Journal Essay - Walden University

Obstetric History: Gravida 2, Para 2, term 2, preterm 0, spontaneous abortion 0, and living 2 (G2T2P2A0L2). Gravida 1: Delivered at 39 weeks by C-section on 4/20/08 male; Gravida 2: Delivered at 40 weeks by C-section on 2/18/15 female. Patient denied therapeutic abortion (TAB) or spontaneous abortion (SAB); Patient denied preterm or low birth weight baby with no delivery complications. Patient also denied having sexual transmitted disease. NURS 6551 Week 9 Practicum Experience Journal Essay - Walden University

Personal/Social History: Patient is married with 2 children, and lives at home with the husband. Patient is a college graduate; works outside the house as a nurse at a nearby hospital. Patient’s husband works for a computer company. Patient family is a middle income family. Also, patient denied any physical or psychological abuse. Patient denied being exposed to any environmental or occupational health hazards. Patient also denied alcohol consumption, tobacco, or recreational drug use. Patient denied participating in any exercise or physical activity because she is tired after work, and prefers to rest. Patient reported that she eats healthy; she eats low fat, low carbohydrate meals, and she eats fruits and vegetable at least 3 to 4 times a week. Patient stated

that she sleeps well at night, and she usually goes to bed at 9 pm and wakes up at 6 am. Patient drinks a cup of coffee occasional, especially when she is at work to be awake. NURS 6551 Week 9 Practicum Experience Journal Essay - Walden University

Review of System (ROS)

General: RG admitted fatigue and weakness; denied fever /chills; and no weight loss.

Head and Neck: Patient denied headache or dizziness. Patient also denied lumps, neck injury, pain/tenderness or jugular vein distention.

Chest: Patient denied chest pain, cough or shortness of breath.

Heart: RG denied irregular heartbeats, heart attack, or heart murmur.

Breasts: Patient denied nipple discharge, tenderness or swelling.

Gastrointestinal: Patient admitted lower abdominal pain, pressure, and bloating; denied constipation, nausea, vomiting, and diarrhea. NURS 6551 Week 9 Practicum Experience Journal Essay - Walden University

Genitourinary: RG denied urinary tract infection, urinary frequency or burning on urination.

Genital: Patient admitted heavy prolonged menstrual bleeding with severe cramping for one year. Patient admitted sharp pelvic pain during menstruation, bleeding between periods, pain with intercourse, and blood clots during periods. Patient denied vaginal discharge. NURS 6551 Week 9 Practicum Experience Journal Essay - Walden University

Musculoskeletal: RG denied varicosities or extremities problem.

Psychiatric: RG denied depression, anxiety, or any psychiatric problems.

Neurological: Patient admitted fatigue and weakness; denied confusion, seizures, or tingling.

Hematologic: Patient admitted history of anemia; denied blood transfusion or easily bruise or bleeding.

Physical Examination

General exam: Patient appeared well developed and pleasant with good hygiene. Patient also appeared pale and weak. Vital signs: Blood pressure 118/76, heart rate 80, respiration 18,

temperature 98.8, pulse ox 100% on room air. Weight 78.2 kg, height 67 inches, and body mass index (BMI) 27.

HEENT: The head is normaceplalic, atraumatic. The pupils are equal, round, and reactive to light and accommodation. Extraocular movements are intact. Tympanic membrane is gray bilaterally. Oral mucosa is dry. Oropharynx is clear. Nares are patient, no nasal or septal deviation noted. No pharyngeal erythema.

Neck: Noted to be supple without jugular vein distention (JVD), thyromegaly or lymphadenopathy. NURS 6551 Week 9 Practicum Experience Journal Essay - Walden University

Lungs: Noted to be clear to auscultation throughout the lobes; no wheezes or rhonchi noted.

Cardiovascular: Regular rate and rhythm on auscultation, S1 S2 present without murmurs. Palpable pulses noted without peripheral edema.

Gastrointestinal: Bowel sounds are active in all quadrant. Abdomen is soft and tender on palpation.

Breast: The size of the breasts, areolas, and nipples are round and symmetrical with no discoloration, rash, lesions, dimpling, or retraction bilaterally; no masses, lumps, or tenderness noted on palpation bilaterally; and axillary lymph nodes non-palpable. NURS 6551 Week 9 Practicum Experience Journal Essay - Walden University

Pelvic Examination:

Vulva: The hair distribution is normal; no lesion noted.

Vagina: Vaginal walls are pink, and pubic hair is shaven; no lesions, masses, inflammation or discharge noted.

Cervix: Intact cervix with closed os.

Uterus: Enlarged, asymmetrical, soft, boggy and tender.

Laboratory and Diagnostic Tests

Laboratory Test and Results: Pregnancy test: Result is negative. Hemoglobin and Hematocrit (H/H): Result showed H/H 8.7/26.7, which is positive for anemia.

Diagnostic:

Transvaginal ultrasonography of the uterus: Revealed uterine enlargement measuring 12 cm with no leiomyomata; uterine wall thickening; cystic anechoic spaces in the myometrium; heterogeneous echo texture; obscured endometrial/myometrial border; sub endometrial echogenic linear striations; and thickening of the transition zone measuring 12.8 millimeter. The transvaginal sonography is used to rule out possible uterine tumor (Sakhel & Abuhamad, 2012). NURS 6551 Week 9 Practicum Experience Journal Essay - Walden University

Magnetic Resonance Imaging (MRI): MRI is ordered to obtain a high resolution image of the uterus as well as verifying/confirming the suspected diagnosis. The MRI result revealed that the junctional zone of the uterus is thickened and measures 12.8 millimeter. Also, MRI revealed an ill-defined ovoid and diffuse region of thickening with striated appearance (Sakhel & Abuhamad, 2012). NURS 6551 Week 9 Practicum Experience Journal Essay - Walden University

Differential Diagnoses

The differential diagnoses of the patient clinical presentation as described by Schuiling and Likis (2013) include: Adenomyosis, uterine fibroids and endometrial hyperplasia. However, the primary diagnosis for the patient is Adenomyosis.

Adenomyosis: Schuiling and Likis (2013) described adenomyosis as a benign, common condition that involves the movement of endometrial tissue into the uterine muscles. The definitive cause of the adenomyosis is unknown, but the condition is common among women with elevated levels of estrogen; the condition usually ceases post menopause when estrogen levels are reduced. Risk factors explained by Taran, Stewart, and Brucker (2013) include multiparity; previous uterine surgery, such as C-section, dilatation/curettage, or fibroids

removal surgery; and women at reproductive age, especially between the age of 40s or 50s. furthermore, Taran et al. (2013) specified that the clinical presentation entails chronic pelvic pain, prolonged menstrual cramps, heavy menstrual bleeding, spotting between periods, abdominal tenderness, painful intercourse, longer periods than normal, blood clots during periods. Taran et al. NURS 6551 Week 9 Practicum Experience Journal Essay - Walden University (2013) also explained that finding during physical examination include enlarged, tender, soft and boggy uterus. According to Taran et al. (2013) diagnosis is made based on sonographic or MRI results, and treatment is not recommended for women with mild form of adenomyosis, except when the symptoms interfere with daily activities. Taran et al. (2013) further explained that treatment options include anti-inflammatory medications; hormonal treatments; endometrial ablation; uterine artery embolization, MRI-guided focused ultrasound surged or hysterectomy, which is the definitive treatment for adenomyosis. NURS 6551 Week 9 Practicum Experience Journal Essay - Walden University

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Adenomyosis is selected as the primary diagnosis because the aforementioned patient’s clinical presentation, physical examination findings, and diagnostic tests results are synonymous with adenomyosis aforementioned associated signs and symptoms; risk factors; physical examination findings; and diagnostic test results.

Uterine Fibroids: Women’s Health (WH, 2015) described uterine fibroid to be muscular tumors that develop in the uterine wall, which can also be referred to as leiomyoma or myoma. Uterine fibroids are usually non-cancerous, and can be single or multiple tumors in the uterus. According to WH (2015), women risk for developing uterine fibroid are increased by age, such as women in their 30s and 40s until menopause when the fibroids commonly shrink. Other risk factors include family history, ethnic origin, obesity and eating habits. Symptoms of fibroids as explained by WH (2015) involve lower back pain; pain during sex; heavy bleeding; painful menses, enlarged lower abdominal, frequent urination; and lower abdominal/pelvic feeling of fullness. Physical examination shows reveal painless, firm, irregular pelvic mass. NURS 6551 Week 9 Practicum Experience Journal Essay - Walden University. According to WH (2015), diagnosis is done using transvaginal ultrasound, MRI, hysteroslpingography, hysteroscopy, and endometrial biopsy. Fibroid is not selected as the primary diagnosis because there is no visualization of the fibroid during pelvic examination or on sonography test. Moreover, severe pain is noted during pelvic exam. Furthermore, sonographic result is more consistent with adenomyosis rather than fibroids. NURS 6551 Week 9 Practicum Experience Journal Essay - Walden University

Endometrial Hyperplasia: Cancer Research of United Kingdom (CRUK, 2014) described endometrial hyperplasia as thickening of the covering of the uterus due to excessive growth of the cells that covers the uterus, and endometrial hyperplasia can lead to womb cancer. Risk factors according to CRUK (2014) include- age over 35 years; white race; nulliparity; older age at menopause; obesity; cigarette smoking; family history of ovarian, colon, or uterine cancer; early menarche; and history of diabetes, polycystic ovary syndrome, thyroid disease and gallbladder disease. NURS 6551 Week 9 Practicum Experience Journal Essay - Walden University. The CRUK (2014), explained that the condition is caused by imbalance of to the estrogen and progesterone. According to CRUK (2014), signs and symptoms of endometrial hyperplasia includes abnormal, prolonged, heavy periods; bleeding between periods; shorter than 21 days’ menstrual cycles; and bleeding after menopause. Also, diagnosis is established by vaginal ultrasound scan, dilatation and curettage, or hysteroscopy. NURS 6551 Week 9 Practicum Experience Journal Essay - Walden University

23rd ed. Philadelphia, PA: Lippincott Williams &.Wilkins; 2014presentation, physical findings during examination; and diagnostic results are not synonymous with the signs and symptoms; physical examination finding, risk factors and diagnostic

results associated with endometrial hyperplasia (American College of Obstetricians and Gynecologist, 2016).

Management Plan

Diagnosis: The only definitive diagnosis of adenomyosis is established after uterus is examined post hysterectomy. However, clinical findings that helped in the diagnosis of the patient includes enlarged, asymmetrical, soft, boggy and tender uterus during pelvic examination and aforementioned sonographic and MRI findings, which synonymous with the diagnosis of adenomyosis (Sakhel & Abuhamad, 2012). NURS 6551 Week 9 Practicum Experience Journal Essay - Walden University

Treatment: Treatment was considered based on the patient clinical presentations, and collaborative agreement with the patient, the author, and the preceptor for total hysterectomy after explanation of the treatment options to the patient. Patient selected hysterectomy because patient does not want to have another child. According to Schuiling and Likis (2013) explanations, patient was advised to continue with the over-the counter anti-inflammatory drug: Motrin 200-400 mg orally every 4-6 hours as needed for pain and cramping until hysterectomy is performed. Also, Ferrous sulfate 325 mg orally three times a day for anemia was prescribed. Patient was educated to take the medication on an empty stomach one hour before meal or 2 hours after meal for optimum absorption. NURS 6551 Week 9 Practicum Experience Journal Essay - Walden University

Patient Education: Patient was educated on the risk factors for adenomyosis, the causes, symptoms, diagnosis, and treatment options. Patient was educated that most women with adenomyosis does not have any symptoms, but adenomyosis is usually found after the tissue obtained from the uterus has been biopsied after pelvic surgery. Patient was also informed that the C-section she had twice during child birth may have put her at risk for adenomyosis. Patient was informed that the symptoms of adenomyosis goes away after menopause or after hysterectomy. Patient was educated that all options of treatment must be tried before hysterectomy, but patient opted for hysterectomy without trying all options of treatment. NURS 6551 Week 9 Practicum Experience Journal Essay - Walden University. furthermore, patient was educated to continue the home remedy, such as continuation of the use of the heating pad, warm soak bath, and continuing with the over the counter Motrin to alleviate the pain associate with the condition. Finally, patient was educated on the psychological and emotional effects of adenomyosis and hysterectomy surgery because some women grieve on the loss of their womb, which may put them into depression as a result of that; the patient has to be completely sure that she really wants to do the surgery at her age now or wait and do the surgery in the future (University of Maryland Medical Center, 2016). NURS 6551 Week 9 Practicum Experience Journal Essay - Walden University

Follow Up Care: In consideration of the Schuiling and Likis (2013) discussion, patient was schedule to follow-up in 6 weeks for follow-up on the patient’s anemia and surgical work up labs, such as complete blood count, complete metabolic panel, prothrombin time and international normalized ratio(PT/INR). Also, an electrocardiogram (EKG) and chest x-ray was ordered to rule out any cardiac problem that would complicate the hysterectomy surgery. NURS 6551 Week 9 Practicum Experience Journal Essay - Walden University. The patient’s H/H came up to 11.5/38.9 and all the other laboratory and diagnostic result was normal. The Total hysterectomy surgery was performed on 7/27/2016. Surgery was successful, and patient was schedule to follow up in six eek post-surgery. NURS 6551 Week 9 Practicum Experience Journal Essay - Walden University

Conclusion Comment by DeAllen B Millender: Level 1 headings are centered, in bold print, and in 'Title Case' (Chapter 3, 3.03, pp. 62-63; see Table 3.1 and Figure 2.1).

The author selected a patient at the author’s clinical site, and obtained a complete health history following the patient care from the beginning of the clinical up to 9 weeks of clinical. The author also used the patient health information and clinical presentation to come up with a diagnosis of adenomyosis. The author developed an appropriate treatment plan with the patient in collaboration with the author’s preceptor incorporating the author’s classroom knowledge with the author’s chosen nursing theorist. Finally, the patient was educated on the condition and follow up care. NURS 6551 Week 9 Practicum Experience Journal Essay - Walden University

References

American College of Obstetricians and Gynecologist. (2016). Endometrial Comment by DeAllen B Millender: Paper and poster titles presented at meetings that are not a part of a symposium should be in italics (Chapter 7, 7.04, p. 206).

Hyperplasia. Retrieved from http://www.acog.org/Patients/

FAQs/Endometrial-Hyperplasia

Cancer Research of United Kingdom. (2014). Endometrial hyperplasia. Retrieved from http://www.cancerresearchuk.org/about-cancer/cancers-in-general/cancer-questions/endometrial-hyperplasia

John Hopkins Medicine. (2016). Recognizing gynecologic problems. Retrieved from http://www.hopkinsmedicine.org/healthlibrary/ NURS 6551 Week 9 Practicum Experience Journal Essay - Walden University

conditions/adult/gynecological_health/recognizing_gynecologic_ problems_85,P00584/

Sakhel, k., & Abuhamad, A. (2012). Sonography of adenomyosis. Journal of Ultrasound in Medicine, 31(12), 805-808. NURS 6551 Week 9 Practicum Experience Journal Essay - Walden University

Schuiling, K. D., & Likis, F. E. (2013). Women’s gynecologic health (2rd ed.). Burlington, MA: Jones and Bartlett Publishers.

Society for Reporoductive Endocrinology and Infertility. (2012). Abnormal uterine bleeding. Retrieved from http://www.socrei.org/BOOKLET_abnormal_uteine_bleeding/ NURS 6551 Week 9 Practicum Experience Journal Essay - Walden University

Taran, F. A., Stewart, E. A., & Brucker, S. (2013). Adenomyosis: Epidemiology, risk factors, clinical phenotype and surgical and interventional alternative to hysterectomy. Geburtshilfe Frauenheilkunde, 73(9), 924-931.

University of Maryland Medical Center. (2016). Adenomyosis. Retrieved from http://umm.edu/health/medical/ency/articles/adenomyosis

Women’s Health. (2015). Uterine fibroids fact sheet. Retrieved from http://www.womenshealth.gov/publications/our-publications/fact-sheet/uterine-fibroids.html#c

NURS 6551 Week 9 Practicum Experience Journal Essay - Walden University