Patient Initials; MHS

Subjective data; the patient is a 28 years old Caucasian woman living in Virginia, USA. She was discharged from the health faculty 2 years ago due to a urinary tract infection. On that occasion she demonstrated a history of having multiple sexual partners. Today, she is experiencing an increased lower abdominal pain, vaginal discharge, and sharp pain upon urination. A clinical diagnostic workup began with the marking of a patient’s initials, MHS gonococcal infection. However, to some extent, the information given by the patient seems unreliable. A clinical diagnostic workup began with the marking of a patient’s initials, MHS gonococcal infection.

Chief Complainant; She stated that she has been a living a healthy lifestyle, adhering to diet restriction and being faithful to only one sexual partner for the last 2 years. “Until now, I am still in utter shock, wondering how I contracted gonorrhea. At the same time, I have been participating in health screening program yearly and not even at once did I feel some pain. I solely blame this on my failure to observe high standard level of hygiene. Additionally, I have never had a breast discharge and I pretty guess that the reason behind the dark urine is as a result of rapid climatic changes. For the last 2 days, I have been having frequent burning upon urination and brownish vaginal discharge.

History of Present Illness- Urinary symptoms that is similar to previous urinary tract infections. At the same time, there was a notification of foul smell. This is a case of recurrent UTIs. Medical history; Tubal ligation. Swabbing of the infected part. Today, it was found that, the bacteria had infected the urethra of MHS.
ROS
Six months ago, she tested positive for dark urine.
Trimethoprim and Sulfamethoxazole

 

Significant Family History- The patient currently lives with a new boyfriend. In a span of 3 years, this was her fourth boyfriend.

Social History- MHS is a Muslim where polygamy is legalized. In equal measures, she sees nothing wrong trying to emulate her male counterparts. In addition, she vehemently denies consuming alcohol and abusing marijuana. However, she admits being a passive smoker since she normally hangs out with close friends who happen to be active smokers. Review of Symptoms- On the other hand, during clinical trials, a healthcare provider’s adherence to the laid down stipulations for Laboratory analysis results to classification of the condition. This should be in tandem with International Classification for Diseases (ICD-10).

Objective data- In collaboration with the National Healthcare Safety Network, it was found that at least 75% of the UTIs were associated with condition referred to as a urinary catheter (Lapides, 2017). Needless to say, conducting a more advanced research in the nursing practice implores to an appropriate pharmacological intervention. Assessment- the ICD-10 comprises of 3 different annotations that constitute of back references must be clearly understood and interpreted by a professional nurse; A54.0, A50-A64 and, A00-B99.

Plan of Care- Moreover, the ICD-10 classification of the code A54.9 has been commonly used by physicians to indicate a diagnosis meant for reimbursement. In the provided scenario, A50-A64 will be ideal to providing clinical information about gonorrhea emanating from its approximate synonyms. In simple terms, the code demonstrates infections resulting from sexual mode of transmission that is predominant. It asserts that gonorrhea is caused by bacterial infection- Neisseria bacteria. During clinical trials, diagnosis index is important towards improving the health outcomes of a patient. Agreeable, in reference to a wide classification of antibiotics like penicillin, ampicillin and amoxicillin, the ICD-10 has been recommended by CDC since it aggravates a possibility of proper administration of medication (Tisler. 2017).

Effectiveness of a Patient Education Tool in Treatment of Urinary Tract Infections

Evaluating subjectivity of the data- There is a need to understand contributing factors of poor management planning. A 10minutes Consultation style is a type of a patient education tool which has been embraced by most of the healthcare providers (Morton, 2017). First and foremost, creating a platform that promotes openness and in return, this prompts positive outcomes. “For the last 5 years, I have been living a healthy lifestyle, adhering to diet restriction and being faithful to only one sexual partner. Until now, I am still in utter shock, wondering how I contracted urinary tract infections.” Notably, there is an urge to ascertain the validity of this information; there is a possibility of biasness. Verification of the provided information becomes possible through delving into history of the patient’s present illness. In a clinical setting, a woman complaining of frequent burning upon urination and vaginal discharge for the past one week needs a timely pharmacological intervention; administration of proper antibiotics. For instance, was tubal ligation performed on the patient? A comprehensive examination enhances a possibility of pertinent diagnostics; differential diagnoses. In most instances, a registered nurse faces challenges upon administration of appropriate medication. In order to prevent high alert medical errors that are as a result of patients’ holding back crucial information, the NO TEARS tool creates a platform for asking specific questions, prompting patient’s compliance.

Conclusion

Until recent, improper administrations of antibiotics in the treatment of gonorrhea have continued to spark societal backlash. This is because, the bacteria has become resistance to antibiotics. With this trend, there is an urge for healthcare providers to form a workable alliance with bodies like CDC. In fact, the body has recommended dual therapy in the treatment, enhancing cultural competency (Reidy, 2017). Until today, the Center for Disease Control has continued to play a pivotal role in promoting wellness and healthiness to a society.

References

1. Weaver, S. J., Lubomksi, L. H., Wilson, R. F., Pfoh, E. R., Martinez, K. A., and Dy, S. M. (2013). Promoting a culture of safety as a patient safety strategy: a systematic review. Annals of internal medicine, 158(5_Part_2), 369-374.

2. Lapides, J., Diokno, A. C., Silber, S. J., and Lowe, B. S. (2017). Clean, intermittent self-catheterization in the treatment of urinary tract disease. The Journal of urology, 197(2), S122-S124.

3. Morton, P. G., Fontaine, D., Hudak, C. M., and Gallo, B. M. (2017). Critical care nursing: a holistic approach (p. 1056). Lippincott Williams and Wilkins.

4. Tisler-Sala, A., Ojavee, S. E., and Uusküla, A. (2017). Treatment of chlamydia and gonorrhoea, compliance with treatment guidelines and factors associated with non-compliant prescribing: findings form a cross-sectional study. Sex Transm Infect, sextrans-2017.

5. Reidy, J., Halvorson, J., Makowski, S., Katz, D., Weinstein, B., McCluskey, C., ... and Tjia, J. (2017). Health system advance care planning culture change for high-risk patients: the promise and challenges of engaging providers, patients, and families in systematic advance care planning. Journal of palliative medicine, 20(4), 388-394.

6. Lipscomb. (2016). Social Theory and Nursing.