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Obstetrics Comprehensive Patient Assessment

When completing practicum requirements in clinical settings, you and your Preceptor might complete several patient assessments in the course of a day or even just a few hours. This schedule does not always allow for a thorough discussion or reflection on every patient you have seen. As a future advanced practice nurse, it is important that you take the time to reflect on a comprehensive patient assessment that includes everything from patient medical history to evaluations and follow-up care. For this Assignment, you begin to plan and write a comprehensive assessment that focuses on one female patient from your current practicum setting.

To prepare

  • Reflect on your Practicum Experience and select a female patient whom you have examined with the support and guidance of your Preceptor.
  • Think about the details of the patient’s background, medical history, physical exam, labs and diagnostics, diagnosis, treatment and management plan, as well as education strategies and follow-up care.

To complete

Write an 8- to 10-page comprehensive assessment that addresses the following:

  • Age, race and ethnicity, and partner status of the patient
  • Current health status, including chief concern or complaint of the patient
  • Contraception method (if any)
  • Patient history, including medical history, family medical history, gynecologic history, obstetric history, and personal social history (as appropriate to current problem)
  • Review of systems
  • Physical exam
  • Labs, tests, and other diagnostics
  • Differential diagnoses
  • Management plan, including diagnosis, treatment, patient education, and follow-up care

References

Learning Resources

Schuiling, K. D., & Likis, F. E. (2017). Women’s  gynecologic health (3rd ed.). Burlington, MA: Jones and Bartlett  Publishers.

Chapter 5, “Gynecologic Anatomy and Physiology” (pp. 77-93)
This chapter explores female anatomy and physiology with a focus on the female reproductive anatomy. It also describes the physiology of the menstrual cycle, including the hormonal feedback system and the ovarian and endometrial cycles.

Chapter 6, “Gynecologic History and Physical Examination” (pp. 95-133)
This chapter identifies the core knowledge and skill base required for obtaining a gynecologic health history and performing physical examinations such as pelvic and breast exams.

Chapter 7, “Periodic Screening and Health Maintenance” (pp. 135-149)
This chapter explores preventive health services for women such as screening tests, counseling, immunization, and chemoprevention. It also compares screening recommendations from organizations such as the U.S. Preventive Services Task Force, American College of Obstetricians and Gynecologists, and American Cancer Society.

Chapter 13, “Intimate Partner Violence” (pp. 303-322)
This chapter defines intimate partner violence (IPV) and describes the epidemiology and health effects of IPV. It also examines screening tools for assessing IPV and strategies for managing patients experiencing IPV, particularly pregnant women, adolescents, and older women.

Chapter 14, “Sexual Assault” (pp. 327-349)
This chapter examines strategies for identifying sexual violence and providing care to women who are victims of sexual violence. It explores potential health consequences of sexual violence on women, including physical injury, spread of sexually transmitted diseases, and unintended pregnancy.

Tharpe, N. L., Farley, C., & Jordan, R. G. (2017). Clinical practice guidelines for midwifery & women’s health (5th  ed.). Burlington, MA: Jones & Bartlett Publishers.
Chapter 6, “Care of the Well Woman Across the Life Span”
“Primary Preventive” Health Care for Well Women” (pp. 301-303)
This section examines social, mental, and physical issues that affect women during different stages of their lives. It also examines the provider’s role in prevention and care.
“Care of the Well Woman: Health Assessment and Screening for Women of Childbearing Age” (pp. 303-310)
This section provides a list of health information for the health care provider to address during well-woman examinations, as well as an immunization schedule for women across the life span.
“Care of the Well Woman: Health Assessment and Screening During Menopause” (pp. 338-349)
This section explains the physiologic changes that occur during menopause, including health issues that are likely to present. It also examines treatment and management options related to diet, exercise, sleep, and sexual comfort.                   Chapter 8, “Primary Care in Midwifery and Women’s Health”
“Care of the Woman: Prevention of Osteoporosis” (pp. 576-584)
This section explores factors that increase risks of osteoporosis in women, particularly postmenopausal women. It also provides strategies for identifying risk factors of osteoporosis and diagnosing and treating the condition.
“Care of the Woman in Need of Smoking Cessation” (pp. 471-475)
This section outlines factors that impact successful smoking cessation. It also describes treatment options and patient education strategies for women in need of smoking cessation.

U.S. Department of Health and Human Services. (2012b). Screening tests and vaccines. Retrieved from http://www.womenshealth.gov/screening-tests-and-vaccines/screening-tests-for-women/

This article provides guidelines for recommended screening tests for women. The guidelines are categorized by age and type of test.

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