Comprehensive Well-Woman Exam
Assignment 2: Comprehensive Well-Woman Exam
For a wide variety of medical conditions, early detection of the problem enables timely and more effective treatment. Annual well-woman exams are among the best tools available for health care professionals to identify potential diseases and medical conditions in women.
Advanced nurse practitioners can play an active role in these important visits. This role can include a physical examination as well as collection of details about such factors as nutrition habits, sexual activity, stress, and more. By participating in comprehensive well-woman exams, advanced nurse practitioners can help patients engage in preventative health.
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For this Assignment, you will complete your well-woman exam using a focused note format in which you will gather patient information, relevant diagnostic and treatment information and reflect on health promotion and disease prevention in light of patient factors, such as age, ethnic group, past medical history (PMH), socio-economic status, cultural background, etc.
Note: All Focused Notes must be signed, and each page must be initialed by your preceptor. When you submit your Focused Notes, you should include the complete Focused Note as a Word document and pdf/images of each page that is initialed and signed by your preceptor. You must submit your Focused Notes using SAFE ASSIGN.
Note: Electronic signatures are not accepted. If both files are not received by the due date, faculty will deduct points per the Walden Late Policies.
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, and treatment and management plan, and education strategies and follow-up care.
• What additional considerations might you think about if your patient was pregnant or just delivered?
• Use the “Guidelines for Comprehensive History and Physical SOAP Note” document found in this week’s Learning Resources to guide you as you complete this Assignment.
Assignment:
Write an 8- to 10-page Comprehensive Well-Woman Exam 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
• Provide evidence-based guidelines to support treatment plan. Note: Use your Learning Resources and evidence from scholarly sources from your personal search to support your treatment plan of care.
Reflection
Reflect on some additional factors for your patient:
• What are the implications if your patient was pregnant or just delivered?
• What are implications if you have observed or know of some domestic violence? Would this change your plan of care? If so, how?
Use your Learning Resources and evidence from scholarly sources from your personal search to support your reflection.
Reminder: The College of Nursing requires that all papers submitted include a title page, introduction, summary, and references. The Sample Paper provided at the Walden Writing Center provides an example of those required elements (available at http://writingcenter.waldenu.edu/57.htm).
Name: PRAC_6552_Week10_Assignment3_Rubric
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Excellent Good Fair Poor
Write an 8- to 10-page Comprehensive Well-Woman Exam 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
• Provide evidence-based guidelines to support treatment plan. 40.5 (40.5%) – 45 (45%)
All required points are addressed, with results that are presented fully and clearly
Provides 5 current and credible scholarly sources to support the treatment plan of care. 36 (36%) – 40 (40%)
At least 8 points are addressed with results that are presented clearly.
Provides at least 4 current and credible scholarly sources to support the treatment plan of care. 31.5 (31.5%) – 35 (35%)
No fewer than 7 points are addressed. One or more results presented in a manner that is vague or incomplete.
Provides at least 3 current and credible scholarly sources to support the treatment plan of care. 0 (0%) – 34 (34%)
Fewer than 7 points are addressed. One or more results are presented in a manner that is vague, incomplete, or inacurrate.
Provides at least 2 current and credible scholarly sources to support the treatment plan of care.
Reflect on the following:
Reflect on some additional factors for your patient:
• What are the implications if your patient was pregnant or just delivered?
• What are implications if you have observed or know of some domestic violence? Would this change your plan of care? If so, how? 36 (36%) – 40 (40%)
Reflection is clearly presented, with implications that are well-formed, clear, and fully expressed.
Provides at least 3 current and credible scholarly sources to support reflection. 32 (32%) – 39 (39%)
Reflection is clearly presented, with implications that are clearly expressed.
Provides at least 3 current and credible scholarly sources to support reflection. 28 (28%) – 31 (31%)
Reflection is presented in manner that is vague or unclear. Implications are not fully or clearly expressed.
Provides at least 2 current and credible scholarly source to support reflection. 0 (0%) – 30 (30%)
Reflection is presented in manner that is vague or unclear. Implications are unclear, or one or both implications not expressed.
Provides at least 1 current and credible scholarly source to support reflection.
Written Expression and Formatting – Paragraph Development and Organization:
Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused—neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction is provided which delineates all required criteria. 5 (5%) – 5 (5%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity.
A clear and comprehensive purpose statement, introduction, and conclusion is provided which delineates all required criteria. 4 (4%) – 4 (4%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity 80% of the time.
Purpose, introduction, and conclusion of the assignment is stated, yet is brief and not descriptive. 3.5 (3.5%) – 3.5 (3.5%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity 60–79% of the time.
Purpose, introduction, and conclusion of the assignment is vague or off topic. 0 (0%) – 3 (3%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity <60% of the time.
No purpose statement, introduction, or conclusion was provided.
Written Expression and Formatting – English writing standards:
Correct grammar, mechanics, and proper punctuation 5 (5%) – 5 (5%)
Uses correct grammar, spelling, and punctuation with no errors. 4 (4%) – 4 (4%)
Contains a few (1 or 2) grammar, spelling, and punctuation errors. 3.5 (3.5%) – 3.5 (3.5%)
Contains several (3 or 4) grammar, spelling, and punctuation errors. 0 (0%) – 3 (3%)
Contains many (≥ 5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding.
Written Expression and Formatting – The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, parenthetical/in-text citations, and reference list. 5 (5%) – 5 (5%)
Uses correct APA format with no errors. 4 (4%) – 4 (4%)
Contains a few (1 or 2) APA format errors. 3.5 (3.5%) – 3.5 (3.5%)
Contains several (3 or 4) APA format errors. 0 (0%) – 3 (3%)
Contains many (≥5) APA format errors.
Total Points: 100
Learning Resources
Required Readings (click to expand/reduce)
Fowler, G. C. (2019). Pfenninger and Fowler’s Procedures for Primary Care (4th ed.). Elsevier.
• Section 10, “Obstetrics”
o Chapter 162, “Dilation and Curettage” (pp. 1093–1099)
Fanslow, J., Wise, M. R., & Marriott, J. (2019). Intimate partner violence and women’s reproductive health. Obstetrics, Gynaecology & Reproductive Medicine, 29(12), 342–350. https://go.openathens.net/redirector/waldenu.edu?url=https://doi.org/10.1016/j.ogrm.2019.09.003
(Previously read in Week 2)
Lockwood, C. J. (2019). Key points for today’s ‘well-woman’ exam: A guide for ob/gyns. Contemporary OB/GYN, 64(1), 23–29. https://search.ebscohost.com/login.aspx?direct=true&db=rzh&AN=134229869&site=ehost-live&scope=site&authtype=shib&custid=s6527200
(Previously read in Week 2)
Document: Guidelines for Comprehensive History and Physical SOAP Note (Word document)
Practicum Resources
Walden University Field Experience. (n.d.-a). Field experience: College of Nursing. https://academicguides.waldenu.edu/fieldexperience/son/home
Walden University Field Experience. (n.d.-c). Student practicum resources: NP student orientation. https://academicguides.waldenu.edu/StudentPracticum/NP_StudentOrientation
Walden University Field Experience. (n.d.-b). MSN nurse practitioner practicum manual. https://academicguides.waldenu.edu/fieldexperience/son/formsanddocuments
HSoft Corporation. (n.d.). Meditrek. https://edu.meditrek.com/Default.html
Note: Use this website to log in to Meditrek to report your clinical hours and patient encounters.
Clinical Guideline Resources
As you review the following resources, you may want to include a topic in the search area to gather detailed information (e.g., breast cancer screening guidelines; for the CDC – zika in pregnancy, etc.).
American Cancer Society. (n.d.). https://www.cancer.org/
American College of Obstetricians and Gynecologists. (n.d.). https://www.acog.org/
ANA Enterprise. (n.d.). https://www.nursingworld.org/
Centers for Disease Control and Prevention. (n.d.). https://www.cdc.gov/
American Association of Nurse Practitioners. (2020). https://www.aanp.org/
HealthyPeople 2030. (2020). Healthy People 2030 framework.
https://www.healthypeople.gov/2020/About-Healthy-People/Development-Healthy-People-2030/Framework
U.S. Preventive Services Task Force. (n.d.-b). Search and filter all recommendation topics. https://www.uspreventiveservicestaskforce.org/uspstf/topic_search_results?topic_status=P&searchterm=
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