HA-RLE Worksheet # 24

ASSESSING FEMALE GENITALIA & RECTUM

Case Study:
Read the following case study. Then work through the steps of analyzing the case study
data.
1. First identify abnormal data and strengths in subjective and objective findings;
Abnormal data Strengths
The client comes to the clinic The client denies any history of cancer
appearing anxious or abnormal Pap smear results
A small amount of malodorous brown The client states that her last pelvic
discharge is noted at the vaginal orifice examination was 6 months ago
A brown discharge is noted on the
cervix
The vaginal walls are pink and moist
with streaks of brown discharge.
Bimanual examination reveals a
mobile, firm, but tender cervix
The right ovary is very tender on
palpation.
Subjective Data:
 The client states that she is experiencing a brown vaginal discharge that
started 2 days ago
 The client states that she states that her last pelvic examination was 6
months ago
 The client denies any history of cancer or abnormal Pap smear results
 The client states that she does not follow any special diet, and does not
exercise on a daily basis.
 The client explained that that she is not comfortable discussing this
problem with her new boyfriend- “I am afraid he might leave me.”
 The client admits to unprotected sex 3 weeks ago with her boyfriend
 The client has never been tested for HIV

Objective Data:
 The client comes to the clinic appearing anxious
 The client has normal hair distribution and no lesions, masses, or swelling.
 The client’s labia majora and labia minora are pink, moist and free of
lesions, excoriation, and swelling
 A small amount of malodorous brown discharge is noted at the vaginal
orifice.
 There is no bulging at the vaginal orifice. The perineum is intact with a
healed episiotomy scar.
 No discharge is observed on urethral palpation. Internal examination
reveals cervix to be slightly anterior and pink, with a slit-like os, and free of
lesions.
 A brown discharge is noted on the cervix.
 The vaginal walls are pink and moist with streaks of brown discharge.
 Bimanual examination reveals a mobile, firm, but tender cervix. The
fundus is palpated at the level of symphysis pubis.
 The ovaries are palpated bilaterally without lesions and are approximately
3 cm.
 The right ovary is very tender on palpation.
 A smooth, firm, mobile, nontender posterior uterine wall and a smooth,
firm, thin, movable rectovaginal septum are palpated during rectovaginal
palpation.
 2. Assemble cue clusters;
 The client The client admits to unprotected sex 3 weeks ago with her
boyfriend
 The client has never been tested for HIV
 A small amount of malodorous brown discharge is noted at the vaginal
orifice.
 A brown discharge is noted on the cervix
 The vaginal walls are pink and moist with streaks of brown discharge
 Bimanual examination reveals a mobile, firm, but tender cervix
 The right ovary is very tender on palpation.

3. Draw inferences;
 The client may have vaginal infection
 The client may be in her menopausal stage

4. Make possible nursing diagnoses;

 Risk for Infection in relation to altered pH of secretion as evidenced by
unprotected sex with her boyfriend as stated by the client.
 Ineffective Health Management related to lack of knowledge of external
genitalia self-examination.

5. Identify defining characteristics;

 The client The client admits to unprotected sex 3 weeks ago with her
boyfriend
6. Confirm or rule out the diagnoses; and
 The defining characteristics set out confirming the diagnosis
7. Document your conclusions.
 Base on the objective and subjective data gathered, the client has Risk for
Infection.

Use the table below to collect subjective and objective data provided to guide you.
Propose nursing diagnoses that are specific to the client in the case study. Identify
collaborative problems, if any, for this client. Finally identify data, if any, which point
toward a medical problem requiring a referral.
Tina Pugh is a 26-year-old white woman. She is a single mother of two and
employed as a paralegal in a law firm. She comes to the clinic appearing anxious. She
states she is experiencing a brown vaginal discharge that started 2 days ago. When
interviewed, she states that her last pelvic examination was 6 months ago. She denies
any history of cancer or abnormal Pap smear results. Her last menstrual period was
normal and ended 1 week ago today. She has never been tested for HIV. She admits to
unprotected sex 3 weeks ago with her boyfriend. A Norplant birth control device was
placed in her left arm 1 year ago. Ms. Tina Pugh denies smoking, states that she does
not follow any special diet, and does not exercise on a daily basis. She explains that
she is not comfortable discussing this problem with her new boyfriend- “I am afraid he
might leave me.”
Your physical assessment reveals normal hair distribution and no lesions,
masses, or swelling. The labia majora and labia minora are pink, moist and free of
lesions, excoriation, and swelling. A small amount of malodorous brown discharge is
noted at the vaginal orifice. There is no bulging at the vaginal orifice. The perineum is
intact with a healed episiotomy scar. No discharge is observed on urethral palpation.
Internal examination reveals cervix to be slightly anterior and pink, with a slit-like os,
and free of lesions. A brown discharge is noted on the cervix. The vaginal walls are pink
and moist with streaks of brown discharge. Bimanual examination reveals a mobile,
firm, but tender cervix. The fundus is palpated at the level of symphysis pubis. The
ovaries are palpated bilaterally without lesions and are approximately 3 cm. the right
ovary is very tender on palpation. A routine Pap smear is performed and culture
specimens are taken. A smooth, firm, mobile, nontender posterior uterine wall and a
smooth, firm, thin, movable rectovaginal septum are palpated during rectovaginal
palpation.
Note: Please secure consent before starting the interview to actual client….
NURSING INTERVIEW GUIDE TO COLLECT SUBJECTIVE DATA
QUESTIONS FINDINGS
Biographical Data
Name (use Code Name or Alyas) Ms. Tina Pugh

Address, Phone Number N/A

Date and Place of Birth N/A

Nationality or Ethnicity N/A

Marital Status Single Mother

Religious or Spiritual Practices N/A

Primary and Secondary Languages English

spoken, written, and read; Birth Language
Educational Level N/A

Occupation and Working Status Employed as a paralegal in a law firm

Who lives with the client? Identify Client’s 2 chilren

significant others
Caregivers and support people for the N/A
client

Present History (Reasons for Seeking Health Care)

What is your major health care or Brown vaginal discharge
concern?

Are you comfortable with seeking care N/A

from this organization? Past Experiences
good or not?

Current symptoms
Menstrual cycle (date of last period, Client states that her last menstrual
regular cycles, length, describe typical period was normal and ended 1 week ago
amount of blood flow, symptoms today.
experience before or during period)?

Age at time of first menstrual period? N/A

Menopause: stop menstruating(if yes, at NO

what age?) or having irregular periods?
What symptoms experienced?

Vaginal discharge (unusual in color, Brown Vaginal Discharge

amount or odor)?

Pain or itching on genitalia or groin? None

Lumps, swelling or masses in genital None
area?

Urinating difficulty, change in urine color, None

or developed and odor? Difficulty
controlling urine?
Problems with sexual performance? None
Recent change in sexual activity pattern None
or libido?
Fertility problems now or in the past? None
Past Health History
Previous gynecologic problems and None
results of any treatment?

Date of last pelvic exam by a physician? Client states that her last pelvic
Date of last Pap smear? Results? examination was 6 months ago. She
denies any history of cancer or abnormal
Pap smear results.
Ever diagnosed with sexually transmitted None
disease (STD) How treated?

Past pregnancies? Number of Two past pregnancies. Has two children

pregnancies? Number of children?
Possibility of being pregnant now?

Previous anal or rectal trauma or surgery, The perineum is intact with a healed
congenital deformities? episiotomy scar.

History of blood in stool? None

Pattern of health screenings(occult blood,
proctosigmoidoscopy, colonoscopy)?
Family History
Family history of reproductive or genital None
cancer? Type? How is the family member
related to you?

Lifestyle and Health Practices

Do you smoke? Or have you smoked in Client denies smoking
the past? Amount and length of time?

Number of sexual partners? One. Her boyfriend

Use of contraceptives? Type? A norplant birth control device was placed

Frequency? theclient’s left arm 1 year ago

Problems with your genitalia that affect N/A

your functioning?

What is your sexual preference? N/A

Comfort level communicating with your Client explains that she is not comfortable
partner your sexual likes and dislikes? discussing this problem with her new
boyfriend-“I am afraid he might leave me.”
Fears related to sex? Do you have stress N/A
related to sex?

Fertility concerns? If so, has this affected N/A

your relationship with partner or family?

Feelings about going through N/A

menopause?

Do you perform monthly genital self- N/A

exams?

Tested for HIV? Results? Why tested? Client states that she has never been
tested with
HIV
Taking estrogen replacement? Length of N/A
treatment? Dosage?

Knowledge of toxic shock syndrome? N/A

Knowledge of sexually transmitted N/A

diseases and their prevention?

Use of laxatives, stool softeners, enemas N/A

and other bowel medications?
Practice anal sex? N/A
Daily water/fluid intake? N/A
Usual diet (high fiber and roughage, Client states that she does not follow any
saturated fat content)? special diet
Usual exercise pattern? Client states that she does not follow any
exercise pattern
Any effect on daily life from anal, rectal or N/A
bowel problems?
PHYSICAL ASSESSMENT GUIDE TO COLLECT OBJECTIVE DATA
Current Symptoms
Gather equipment (stool, light, speculum, N/A
emesis basin filled with warm tap water,
Surgilube, cotton-tipped applicators,
Chlamydia culture tubes, culturette, test
tube with water, sterile gloves, Ayre
spatula (wood stick) and feminine
napkins)
Explain the procedure to the client N/A

Ask the client to put on gown N/A

External Genitalia
Inspect the mons pubis. Note pubic hair Inspection reveals even hair distribution
distribution, signs of infestation with no signs of infestation.

Inspect the labia majora and perineum. The labia majora and labia minora are
Note lesions, swelling, excoriation pink, moist and free of lesions,
excoriation, and swelling. Asmall amount
of malodorous brown discharge is noted
at the vaginal orifice. There is no bulging
at the vaginal orifice. The perineum is
intact with a healed episiotomy scar.
Inspect the labia minora, clitoris, urethral The labia majora and labia minora are
meatus and vaginal opening. Note pink, moist and free of lesions,
lesions, excoriation, swelling, discharge. excoriation, and swelling. A small amount
of malodorous brown discharge is noted
at the vaginal orifice. There is no bulging
at the vaginal orifice. The perineum is
intact with a healed episiotomy scar.
Palpate the Bartholin’s glands (if history N/A
of swelling or current swelling noted) Note
swelling, tenderness, discharge.

Palpate the urethra (if client complaints of No discharge is observed on urethral

urethral symptoms or urethritis or palpation
inflammation of Skene’s glands is
suspected) by inserting gloved index
fingers into the superior portion of the
vagina and milking the urethra from the
inside, pushing up and out. Observe for
drainage.

Internal Genitalia
Inspect the size of the vaginal opening The vaginal walls are pink and moist with
and the angle of the vagina by moistening streaks of brown discharge.
gloved index finger with warm water and
gently inserting the finger into the vagina
Assess the vaginal musculature by There is no bulging at the vaginal orifice.
keeping index finger inserted in the
vaginal opening and asking the patient o
squeeze around your finger. Using middle
and index fingers to separate the labia
minora, ask client to bear down. Observe
for bulging or discharge of urine
Perform the speculum examination: Internal examination reveals cervix to be
a. Inspect the cervix for color, size, slightlyanterior and pink, with a slit-like
position, surface, os, discharge or lesions os, and free of lesions.
b. Obtain specimens for the pap smear
and if indicated, culture to test for STDs A brown discharge is noted on the cervix.
c. Inspect the vagina, unlocking the The vaginal walls are pink and moist with
speculum and inspecting the vagina as streaks of brown discharge
the partially open speculum is slowly
rotated and removed. Note color, surface,
consistency and discharge
Perform the bimanual examination by Bimanual examination reveals a mobile,
placing non dominant hand on lower firm, but tender cervix.
abdomen and inserting gloved lubricated
index and middle fingers into the vaginal
opening, applying pressure to the
posterior wall, amd waiting for the
opening to relax. Palpate the ovaries by
sliding your intravaginal fingers to the
right lateral fornix and attempting to
palpate the left and then the right ovaries.
Note size, shape, consistency, mobility
and tenderness. Observe for secretions
as fingers are withdrawn.
Perform the rectovaginal examination by A smooth, firm, mobile, nontender
changing gloves on dominant hand and posterior uterine wall and a smooth, firm,
lubricating index and middle fingers. Ask thin, movable rectovaginal septum are
client to bear down. Insert index finger palpated during rectovaginal palpation.
into the vagina and middle finger into the
rectum. While pushing down on the
abdominal wall with the other hand,
palpate the internal reproductive
structures through the anterior rectal wall,
with attention to the area behind the
cervix, the rectovaginal septum, the cul-
de-sac and the posterior uterine wall.
Anus and Perianal Area
Inspect for lumps, ulcers, lesions, rashes, N/A
redness (note size, shape, location,
distribution and configuration)
Inspect the sacrococcygeal area for N/A
swelling, redness, dimpling or presence
of hair in pilonidal area
Inspect for rectal prolapse with Valsalva N/A
maneuver
Palpate for anal sphincter tone, N/A
tenderness, nodules or hardness
Rectum
Palpate rectal mucosa for tenderness, N/A
irregularities, nodules and hardness
Palpate peritoneal cavity for tenderness N/A
and nodules or “rectal shelf”
Inspect the feces for blood and perform N/A
occult blood test

Analysis
Formulate nursing diagnoses (wellness, Risk for Infection in relation to altered pH
risk, actual) of secretion as evidenced by unprotected
sex with her boyfriend as stated by the
client.

Ineffective Health Management related to

lack of knowledge of external genitalia
self-examination.
Formulate collaborative problems RC: Pregnancy
RC: Vaginal Bleeding

Make necessary referrals N/A

Reference:
Weber, J., Kelley, J. and Sprengel, A. (2014). Lab Manual for Health Assessment in
Nursing. 5th Edition. Philadelphia: Wolters Kluwer Health/Lippincott Williams &
Wilkins.
NURSING CARE PLAN
Name of Tina Pugh Rm/Bed No. N/A Age 26 Chief Brown Vaginal Discharge
Patient Complaints
Address N/A Admission N/A Sex Female Diagnosis Ineffective Health Management
Date

ASSESSMENT HEALTH NURSING DESIRED INTERVENTION EVALUATION REMARKS

PATTERN DIAGNOSIS OUTCOME
Subjective Cues: Health Ineffective Health After 4 hours of Observe early signs of pregnancy and GOAL MET PT WAS ABLE
Pt. reported Promotion Management related to intervention the other causes of infection and later on TO:
Brown Vaginal lack of knowledge of patient will be able to health educate the client.
Discharge Activity/ external genitalia self-
be show signs of RATIONALE: This will help the client A. Demonstrate
Exercise examination improvement, to detect early signs of pregnancy and self-pelvic
specifically will be other signs of infection, in order for me examination
Nutrition/ Risk for Infection in able to: to assess infections as early as B. Uses safety
Metabolism relation to altered pH possible. measures to
of secretion as A. Demonstrate minimize
evidenced by self-pelvic Ensure therapeutic communication with C. Perform
unprotected sex with examination the partner and patient. physical
her boyfriend as stated B. Uses safety RATIONALE: This will ease the Activity
by the client. measures to observation and collecting of data and independently or
minimize gives opportunity for student nurse like within limits of
C. Perform physical me to learn as much as possible about disease.
Background Activity the patient’s activities of daily living.
Knowledge independently or
Objective Cues within limits of Assist the client’s partner in referring to
disease. a physician as appropriate.
A small amount of RATIONALE: A physician can help
Malodorous check
brown discharge and provide specialized services in
is noted at the
vaginal orifice.
*A brown
discharge is noted
on the cervix.
*The vaginal walls
are pink and
moist with streaks
of brown
discharge.
*Bimanual
examination
reveals a mobile,
firm, but tender
cervix. promoting safety interventions.