Instructions
In this assignment, you will review the patient scenario and analyze the data to determine the health status of the patient.
Use the NU664D Prolapse Case Study Questions (Word) document to complete the case study assignment.
Follow the requirements posted in the rubric.
Case studies should be three to five pages, excluding title and references pages.
At the end of your case study, ensure you add any pertinent guidelines, screening recommendations, protocols, or treatments to your pocket guide assignment.
All papers must conform to the most recent APA standards.
Prolapse Case Study Patient Scenario
Janice a 78-year-old G4 P4 presents to the office with a complaint of urinary frequency, urgency and a sensation of feeling as if she is sitting on a ball. She states she feels pressure in her lower abdomen and back. She is very healthy and tries to exercise but has been limited secondary to discomfort.
Past Medical History
Hypothyroid
Constipation
Psychosocial history is negative
Medications
Levothyroxine
Calcium
Vitamin D
Answer These Questions
What other subjective data do you need to gather today?
What objective data would you gather today?
Exam Findings:
PE is T 98.6 P 82, R 16, B/P 112/74
Abdomen soft NT without masses
Pelvic exam reveals – female external with urethral caruncle
Vulva is negative with loss of labial folds secondary to atrophy – no obvious abnormalities
Vagina is with scant discharge, atrophic, moderate vaginal vault prolapse.
Cervix is primiparous – CMT
Cervix is primiparous – CMT
Uterus small, non tender no masses
Ovaries non palpable
Rectal negative
On Valsalva – +grade 2 cystocele
What is your assessment of this patient? Include ICD10 code and rationale.
Your patient states she doesn’t want any surgical intervention. Complete a plan of care for this patient including, diagnostics, pharmacological and non-pharmacological treatment, education, including primary and secondary prevention, referrals, and follow up.
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