Gynecologic Health History

CAGE Questionnaire CAGE Questionnaire • Have you ever felt you should Cut down on your drinking? • Have you ever felt you should Cut down on your drinking? • Have people Annoyed you by criticizing your drinking? • Have people Annoyed you by criticizing your drinking? • Have you ever felt bad or Guilty about your drinking? • Have you ever felt bad or Guilty about your drinking? • Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a • Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover (Eye opener)? hangover (Eye opener)? Scoring: Scoring: Item responses on the CAGE are scored 0 or 1, with a higher score an indication of alcohol problems. A total score of 2 or greater is considered clinically significant. Gynecologic Health History

Item responses on the CAGE are scored 0 or 1, with a higher score an indication of alcohol problems. A total score of 2 or greater is considered clinically significant. ……………………………….. ……………………………….. Developed by Dr. John Ewing, founding Director of the Bowles Center for Alcohol Studies, University of North Carolina at Cahpel Hill, CAGE is an internationally used assessment instrument for identifying alcoholics. It is particularly popular with primary care givers. CAGE has been translated into several languages. Developed by Dr. John Ewing, founding Director of the Bowles Center for Alcohol Studies, University of North Carolina at Cahpel Hill, CAGE is an internationally used assessment instrument for identifying alcoholics. It is particularly popular with primary care givers. CAGE has been translated into several languages. The CAGE questions can be used in the clinical setting using informal phrasing. It has been demonstrated that they are most effective when used as part of a general health history and should NOT be preceded by questions about how much or how frequently the patient drinks (see “Alcoholism: The Keys to the CAGE” by DL Steinweg and H Worth; American Journal of Medicine 94: 520-523, May 1993. The CAGE questions can be used in the clinical setting using informal phrasing. It has been demonstrated that they are most effective when used as part of a general health history and should NOT be preceded by questions about how much or how frequently the patient drinks (see “Alcoholism: The Keys to the CAGE” by DL Steinweg and H Worth; American Journal of Medicine 94: 520-523, May 1993. The exact wording that can be used in research studies can be found in: JA Ewing “Detecting Alcoholism: The CAGE Questionaire” JAMA 252: 1905-1907, 1984. Researchers and clinicians who are publishing studies using the CAGE Questionaire should cite the above reference. No other permission is necessary unless it is used in any profit-making endeavor in which case this Center would require to negotiate a payment. The exact wording that can be used in research studies can be found in: JA Ewing “Detecting Alcoholism: The CAGE Questionaire” JAMA 252: 1905-1907, 1984. Researchers and clinicians who are publishing studies using the CAGE Questionaire should cite the above reference. No other permission is necessary unless it is used in any profit-making endeavor in which case this Center would require to negotiate a payment. ……………………………….. ……………………………….. Source: Dr. John Ewing, founding Director of the Bowles Center for Alcohol Studies, University of North Carolina at Chapel Hill 012695 (02-2004) To reorder, call 1-877-638-7827 Source: Dr. John Ewing, founding Director of the Bowles Center for Alcohol Studies, University of North Carolina at Chapel Hill 012695 (02-2004) To reorder, call 1-877-638-7827 NRNP 6552: Advanced Nurse Practice in Reproductive Health Care Episodic/Focused SOAP Note Template Patient Information: Initials, Age, Sex, Race S. CC (chief complaint): This is a brief statement identifying why the patient is here in the patient’s own words, for instance, “headache,” not “bad headache for 3 days.” HPI: This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. Use LOCATES Mnemonic to complete your HPI. You need to start every HPI with age, race, and gender (e.g., 34-year-old African American male). You must include the seven attributes of each principal symptom in paragraph form, not a list. If the CC was “headache,” the LOCATES for the HPI might look like the following example: Location: head Onset: 3 days ago Character: pounding, pressure around the eyes and temples Associated signs and symptoms: nausea, vomiting, photophobia, phonophobia Timing: after being on the computer all day at work Exacerbating/relieving factors: light bothers eyes, Naproxen makes it tolerable but not completely better Severity: 7/10 pain scale Current Medications: Include dosage, frequency, length of time used, and reason for use. Also include over-the-counter (OTC) or homeopathic products. Allergies: Include medication, food, and environmental allergies separately. Provide a description of what the allergy is (e.g., angioedema, anaphylaxis).

This will help determine a true reaction versus intolerance. PMHx: Include immunization status (note date of last tetanus for all adults), past major illnesses, and surgeries. Depending on the CC, more info is sometimes needed. © 2020 Walden University 1 NRNP 6552: Advanced Nurse Practice in Reproductive Health Care Soc & Substance Hx: Include occupation and major hobbies, family status, tobacco and alcohol use (previous and current use), and any other pertinent data. Always add some health promotion questions here, such as whether they use seat belts all the time or whether they have working smoke detectors in the house, the condition of the living environment, text/cell phone use while driving, and support systems available. Fam Hx: Illnesses with possible genetic predisposition, contagious illnesses, or chronic illnesses. The reason for death of any deceased first-degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent. Surgical Hx: Prior surgical procedures. Mental Hx: Diagnosis and treatment. Current concerns: (Anxiety and/or depression). History of self-harm practices and/or suicidal or homicidal ideation. Violence Hx: Concern or issues about safety (personal, home, community, sexual— current and historical). Reproductive Hx: Menstrual history (date of last menstrual period [LMP]), pregnant (yes or no), nursing/lactating (yes or no), contraceptive use (method used), types of intercourse (oral, anal, vaginal, other), and any sexual concerns. ROS: This covers all body systems that may help you include or rule out a differential diagnosis. You should list each system as follows: General: Head: EENT: and so forth. You should list these in bullet format and document the systems in order from head to toe. Example of Complete ROS: GENERAL: No weight loss, fever, chills, weakness, or fatigue. Gynecologic Health History

HEENT: Eyes: No visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat. SKIN: No rash or itching. CARDIOVASCULAR: No chest pain, chest pressure, or chest discomfort. No palpitations or edema. RESPIRATORY: No shortness of breath, cough, or sputum. GASTROINTESTINAL: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood. GENITOURINARY: Burning on urination. Pregnancy. LMP: MM/DD/YYYY. © 2020 Walden University 2 NRNP 6552: Advanced Nurse Practice in Reproductive Health Care NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control. MUSCULOSKELETAL: No muscle pain, back pain, joint pain, or stiffness. HEMATOLOGIC: No anemia, bleeding, or bruising. LYMPHATICS: No enlarged nodes. No history of splenectomy. PSYCHIATRIC: No history of depression or anxiety. ENDOCRINOLOGIC: No reports of sweating or cold or heat intolerance. No polyuria or polydipsia. Gynecologic Health History

REPRODUCTIVE: Not pregnant and no recent pregnancy. No reports of vaginal or penile discharge. Not sexually active. ALLERGIES: No history of asthma, hives, eczema, or rhinitis. O. Physical exam: From head to toe, include what you see, hear, and feel when conducting your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and history. Do not use “WNL” or “normal.” You must describe what you see. Always document in head-to-toe format (i.e., General: Head: EENT:). Diagnostic results: Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines). A. Differential Diagnoses (list a minimum of 3 differential diagnoses). Your primary or presumptive diagnosis should be at the top of the list. For each diagnosis, provide supportive documentation with evidence-based guidelines. P. Includes documentation of diagnostic studies that will be obtained, referrals to other health care providers, therapeutic interventions, education, disposition of the patient, and any planned follow-up visits. Each diagnosis or condition documented in the assessment should be addressed in the plan. The details of the plan should follow an orderly manner. Also included in this section is the reflection. The student should reflect on this case and discuss whether or not they agree with their preceptor’s treatment of the patient and why or why not. What did they learn from this case? What would they do differently? © 2020 Walden University 3 NRNP 6552: Advanced Nurse Practice in Reproductive Health Care Also include in your reflection a discussion related to health promotion and disease prevention, taking into consideration patient factors (e.g., age, ethnic group), PMH, and other risk factors (e.g., socioeconomic, cultural background). References You are required to include at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines that relate to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 7th edition formatting. © 2020 Walden University 4 Rubric Detail Select Grid View or List View to change the rubric’s layout. Name: NRNP_6552_Module1_Assignment_Rubric Grid View EXIT List View Excellent Good Fair Poor 27 (27%) – 30 (30%) 24 (24%) – 26 (26%) 21 (21%) – 23 (23%) 0 (0%) – 20 (20%) The response provides clear, complete, and appropriate descriptions of a comprehensive gynecologic history. Health maintenance guidelines are clear and complete. Social factors a!ecting health are appropriately incorporated. The response provides clear, complete, and most of the components of a comprehensive gynecologic history. Gynecologic Health History

Most health maintenance guidelines are included and appropriate. Social factors a!ecting health are mostly included. The response provides components of the gynecologic history but they are incomplete, vague or inaccurate. Health maintenance guidelines are somewhat complete or inappropriate applied. Social factors are included but some are missing. The response provides unclear, incomplete, or inappropriate components of the gynecologic health history. Health maintenance guidelines are missing, incorrect, or inappropriate applied. Social factors are missing or incorrect. Building a Health History: Asking Di!cult Questions Create your own script for building a health history. Consider the type of language you would use to help your patient be more comfortable). Ensure you include the di!cult questions required to complete a thorough health history. 22.5 (22.5%) – 25 (25%) 20 (20%) – 22 (22%) 17.5 (17.5%) – 19.5 (19.5%) 0 (0%) – 17 (17%) The script contains a complete set of questions, including di”cult questions, necessary to build a health history. Questions are phrased in a manner that supports the patients comfort. The script contains a mostly complete set of questions, including di”cult questions, necessary to build a health history. Most questions are phrased in a manner that supports the patients comfort.

The script containing some relevant questions, including a few di”cult questions. Information collected provides a cursory health history. Questions are not phrased in a supportive tone. The script contains few or no relevant questions, including few or no di”cult questions. Information collected is not su”cient to provide an adequate health history. Questions are not phrased in a supportive tone. In addition to your script for building a health history for this assignment, include a separate section called “Re”ection” 27 (27%) – 30 (30%) 24 (24%) – 26 (26%) 21 (21%) – 23 (23%) 0 (0%) – 20 (20%) The response provides an accurate, clear, and complete summary of experiences in developing the script during the health history The response provides an accurate summary of experiences in developing the script during the health history The response provides a vague, inaccurate, or incomplete summary of the experiences in developing the script during the health history The response provides a vague, inaccurate, or incomplete summary of the experiences in developing the script during the health history, or the summary is missing. Written Expression and Formatting – Paragraph Development and Organization: Paragraphs make clear points that support well-developed ideas, “ow 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%) 4 (4%) – 4 (4%) 3.5 (3.5%) – 3.5 (3.5%) 0 (0%) – 3 (3%) Paragraphs and sentences follow writing standards for #ow, continuity, and clarity. Paragraphs and sentences follow writing standards for #ow, continuity, and clarity 80% of the time. Paragraphs and sentences follow writing standards for #ow, continuity, and clarity 60%–79% of the time. Paragraphs and sentences follow writing standards for #ow, continuity, and clarity < 60% of the time. Purpose, introduction, and conclusion of the assignment is stated, yet is brief and not descriptive. Purpose, introduction, and conclusion of the assignment is vague or o! topic. 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%) 4 (4%) – 4 (4%) 3.5 (3.5%) – 3.5 (3.5%) 0 (0%) – 3 (3%) Uses correct grammar, spelling, and punctuation with no errors. Contains a few (1 or 2) grammar, spelling, and punctuation errors. Contains several (3 or 4) grammar, spelling, and punctuation errors. 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%) 4 (4%) – 4 (4%) 3.5 (3.5%) – 3.5 (3.5%) 0 (0%) – 3 (3%) Uses correct APA format with no errors. Contains a few (1 or 2) APA format errors. Contains several (3 or 4) APA format errors. Contains many (≥ 5) APA format errors. Describe the components of a comprehensive gynecologic health history. Include considerations for special populations such as LGBTQ+ individuals. What health maintenance guidelines should be included during the initial and follow up assessments. (i.e., bone density test, Gardasil vaccine, shingles, etc.)? What questions would you consider in your patient’s assessment? For example • What is your patient’s living situation? • Do they have stairs? • Do they live by themselves? • Do they have a working refrigerator? Brie”y re”ect and provide a summary of your experiences in developing your script during your health history. A clear and comprehensive purpose statement, introduction, and conclusion is provided which delineates all required criteria. Total Points: 100 Name: NRNP_6552_Module1_Assignment_Rubric EXIT …Gynecologic Health History