GENITOURINARY CLINICAL CASE CARE PLAN

GENITOURINARY CLINICAL CASE CARE PLAN

GENITOURINARY CLINICAL CASE CARE PLAN

Visit the South University Online Library and research for current scholarly evidence (no older than 5 years) to support your nursing actions. In addition, consider visiting government sites such as the Centers for Disease Control and Prevention (CDC), the World Health Organization (WHO), the Agency for Healthcare Research and Quality (AHRQ), and Healthy People 2020. Provide a detailed scientific rationale justifying the inclusion of this evidence in your plan.
Download and analyze the case study for this week. Create a holistic care plan for disease prevention, health promotion, and acute care of the patient in the clinical case. Your care plan should be based on current evidence and nursing standards of care.
Next determine the ICD-10 classification (diagnoses). The International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-10-CM) is the official system used in the United States to classify and assign codes to health conditions and related informat.

GENITOURINARY CLINICAL CASE CARE PLAN

You are expected to develop a comprehensive care plan based on your assessment, diagnosis, and advanced nursing interventions. Reflect on what you have learned about care plans through independent research and peer discussions, and incorporate the knowledge that you have gained into your patient’s care plan.
Genitourinary Case Study
Patient Initials __28-year-old Female
Subjective Data: 28-year-old female presents to the clinic with history of burning pain upon urination, increased lower abdominal pain and vaginal discharge of the past week;
Chief Compliant: complaints of urinary symptoms similar to those of previous UTIs started two days ago also complains of severe lower abdominal pain and follow smelling brown discharge’
History of Present Illness: the patient complains of urinary symptoms like those of previous urinary tract infection. started two days ago; patient is also experiencing severe lower abdominal pain is noted to have Brown foul smelling discharge, following of unprotective intercourse with her boyfriend.
PMH UTIs, patient has three this year, gonorrhea x 2, chlamydia times x1 Gravida IV III
Medical/Surgical History: the patient reports tubal ligation two years ago
Significant Family History: none
Social History:   pt is single with multiple sexual partners. Patient has three children, denies smoking alcohol or drug use.
Medication history: patient does not have any current prescriptions, allergic to Trimethoprim and Sulfamethoxazole(rash) last pap was six months ago, denies breast discharge, positive for urine looking dark
Objective Data:
Vital Signs: 
BP  100/80
HR 80
RR 16
Temp 99.7
WT 120
HT 5 feet
Physical Exam
Review of Symptoms (ROS) findings
General: female moderate distress
HEENT PERRLA, WNL

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Cardiovascular Regular rate and rhythm, normal S1 and S2
Chest WNL
Respiratory clear to auscultation
Abdominal, soft, tender, increased suprapubic tenderness
Genitourinary: cervical motion tenderness, adnexal tenderness, foul-smelling bad discharge
Rectal WNL
EXT WNL
Neurological WNL
Psychiatric moderate distress
Laboratory and diagnostic testing

Differential diagnoses
1.      Gonococcal cervicitis, unspecified, ICD-10-CM Diagnosis Code A54.03
Plan of care: N, gonorrhoeae is a fastidious gram-negative intraocular diplococcus. According to treatment guidelines from the (WHO) World Health Organization, treatment should consist of ceftriaxone 250 mg intramuscular (IM) as a single dose PLUS azithromycin 1 g orally as a single dose. (WHO Neisseria gonorrhoeae,2016). Patient education, according to the CDC fact sheet on gonorrhea, gonorrhoeae essentially transmitted disease that can affect both men and women, it can cause infection in the genitals rectum and throat is a very common infection especially among young people ages 15 to 24. You can reduce the risk of getting gonorrhea, if you are sexually active you can do the following things to you decrease your chance of getting gonorrhea being a long-term relationship (Monogamous). Use latex condoms every time you have sex. (CDC fact sheet,2018)
2. Chlamydial infection of genitourinary tract, unspecified. 10-CM Diagnosis Code A56.2Plan of care. According to the who will help organization guidelines treatment for chlamydia, azithromycin 1 g orally as a single dose doxycycline hundred milligrams b.i.d. or seven days seven days. Patient education, Chlamydia is a common STD that can affect both men and women. You can cause serious permanent damage to a woman’s reproductive system. The only way to avoid STDs as to not have agile and or oral sex be a long-term monogamous relationship with a partner has been tested negative for STD, use latex condoms every time you have sex. Anon, (2019). STD Facts
3. Personal history of urinary (tract) infections, ICD-10-CM Diagnosis Code Z87.440. plan of care Cipro flaxen 500 mg twice a day for seven days, for treatment of urinary tract infection. According to internal article on the guidelines of treating UTI. According to the CDC fact sheet UTIs are caused by bacteria and are treated with antibiotics. Take antibiotics as the doctor tells you, do not share and about others and do not save them for later. You can help prevent UTIs by doing the following unit after sexual activity, shall instead of baths, minimize douching sprays or powers the genital area (. Kang, C. I 2018)
Important information for writing discussion questions and participation
Welcome to class
Hello class and welcome to the class and I will be your instructor for this course. This is a -week course and requires a lot of time commitment, organization, and a high level of dedication. Please use the class syllabus to guide you through all the assignments required for the course. I have also attached the classroom policies to this announcement to know your expectations for this course. Please review this document carefully and ask me any questions if you do. You could email me at any time or send me a message via the “message” icon in halo if you need to contact me. I check my email regularly, so you should get a response within 24 hours. If you have not heard from me within 24 hours and need to contact me urgently, please send a follow up text to
I strongly encourage that you do not wait until the very last minute to complete your assignments. Your assignments in weeks 4 and 5 require early planning as you would need to present a teaching plan and interview a community health provider. I advise you look at the requirements for these assignments at the beginning of the course and plan accordingly. I have posted the YouTube link that explains all the class assignments in detail. It is required that you watch this 32-minute video as the assignments from week 3 through 5 require that you follow the instructions to the letter to succeed. Failure to complete these assignments according to instructions might lead to a zero. After watching the video, please schedule a one-on-one with me to discuss your topic for your project by the second week of class. Use this link to schedule a 15-minute session. Please, call me at the time of your appointment on my number. Please note that I will NOT call you.
Please, be advised I do NOT accept any assignments by email. If you are having technical issues with uploading an assignment, contact the technical department and inform me of the issue. If you have any issues that would prevent you from getting your assignments to me by the deadline, please inform me to request a possible extension. Note that working fulltime or overtime is no excuse for late assignments. There is a 5%-point deduction for every day your assignment is late. This only applies to approved extensions. Late assignments will not be accepted.
If you think you would be needing accommodations due to any reasons, please contact the appropriate department to request accommodations.
Plagiarism is highly prohibited. Please ensure you are citing your sources correctly using APA 7th edition. All assignments including discussion posts should be formatted in APA with the appropriate spacing, font, margin, and indents. Any papers not well formatted would be returned back to you, hence, I advise you review APA formatting style. I have attached a sample paper in APA format and will also post sample discussion responses in subsequent announcements.
Your initial discussion post should be a minimum of 200 words and response posts should be a minimum of 150 words. Be advised that I grade based on quality and not necessarily the number of words you post. A minimum of TWO references should be used for your initial post. For your response post, you do not need references as personal experiences would count as response posts. If you however cite anything from the literature for your response post, it is required that you cite your reference. You should include a minimum of THREE references for papers in this course. Please note that references should be no more than 5 years old except recommended as a resource for the class. Furthermore, for each discussion board question, you need ONE initial substantive response and TWO substantive responses to either your classmates or your instructor for a total of THREE responses. There are TWO discussion questions each week, hence, you need a total minimum of SIX discussion posts for each week. I usually post a discussion question each week. You could also respond to these as it would count towards your required SIX discussion posts for the week.
I understand this is a lot of information to cover in 5 weeks, however, the Bible says in Philippians 4:13 that we can do all things through Christ that strengthens us. Even in times like this, we are encouraged by God’s word that we have that ability in us to succeed with His strength. I pray that each and every one of you receives strength for this course and life generally as we navigate through this pandemic that is shaking our world today. Relax and enjoy the course!
Hi Class,
Please read through the following information on writing a Discussion question response and participation posts.
Contact me if you have any questions.
Important information on Writing a Discussion Question

• Your response needs to be a minimum of 150 words (not including your list of references)
• There needs to be at least TWO references with ONE being a peer reviewed professional journal article.
• Include in-text citations in your response
• Do not include quotes—instead summarize and paraphrase the information
• Follow APA-7th edition
• Points will be deducted if the above is not followed

Participation –replies to your classmates or instructor

• A minimum of 6 responses per week, on at least 3 days of the week.
• Each response needs at least ONE reference with citations—best if it is a peer reviewed journal article
• Each response needs to be at least 75 words in length (does not include your list of references)
• Responses need to be substantive by bringing information to the discussion or further enhance the discussion. Responses of “I agree” or “great post” does not count for the word count.
• Follow APA 7th edition
• Points will be deducted if the above is not followed

• Remember to use and follow APA-7th edition for all weekly assignments, discussion questions, and participation points.
• Here are some helpful links
• Student paper example
• Citing Sources
• The Writing Center is a great resource

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