FNP592 WEEK 1 TO 8 DISCUSSIONS AND ASSIGNMENTS SOAP NOTES | GET INSTANT WRITING HELP

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Week 1: Discussion Question – Clinical Practice

 

Discuss your plan for completing your clinical hours. What specific skills or goals would you like to accomplish during this clinical rotation? How do you plan to use evidence to support your clinical decisions?

Expectations

Initial Post:

  • Due: Thursday, 11:59 pm PT
  • Length: A minimum of 300 words, not including references
  • Citations: At least 4-5 high-level scholarly reference in APA from within the last 5 years

Week 2: Discussion Question – Evidence-Based Practice

Diabetes is a common illness seen in primary care.  Using evidence-based practice, what screening would you need to make to ensure these patients are getting adequate care and health promotion.

Expectations

Initial Post:

  • Due: Thursday, 11:59 pm PT
  • Length: A minimum of 300 words, not including references
  • Citations: At least 4-5 high-level scholarly reference in APA from within the last 5 years

Week 3: Discussion Question – Diagnosis Presentation

For discussion this week, students will post a presentation for review and discussion among other students. Please post your presentation by Thursday. You may use feedback from your peers to help improve the presentation, which will be then submitted to the assignment dropbox on Monday night. There will be two grades associated with this project; the weekly discussion grade and also the instructor’s grade of the presentation itself, in the assignment dropbox Please see the presentation assignment prompt for more details.

Expectations

Initial Post:

  • Due: Thursday, 11:59 pm PT
  • Length: 10-12 slides in length (excluding title and reference slides, with a maximum recording length of 20 minutes)
  • Format: PPT titled as follows:
  • Last name_DiagnosisPresentation1_mmddyyyy
  • Example: Billingsley_CholecystitisPresentation1_01172020
  • Citations: At least 6-7 high-level scholarly references in APA from within the last 5 years

Week 4: Discussion Question – Population Based Health

Pick a specific population within your clinical environment or community and discuss the overall health of that population – morbidity, mortality, health behaviors, risk factors, barriers to access, etc. Identify a targeted health issue or health promotion service/program that is needed or being utilized and discuss the benefits/downfalls or pros/cons. Reference and citations required.

Expectations

Initial Post:

  • Due: Thursday, 11:59 pm PT
  • Length: A minimum of 300 words, not including references
  • Citations: At least 4-5 high-level scholarly reference in APA from within the last 5 years

Week 5: Discussion Question – Clinical Resources

Resources are an important part of daily practice.  Identify and describe two resources you have seen being used in clinic that are helpful in determining diagnosis, assessment or treatment plans.  Citation and reference required.

Expectations

Initial Post:

  • Due: Thursday, 11:59 pm PT
  • Length: A minimum of 300 words, not including references
  • Citations: At least 4-5 high-level scholarly reference in APA from within the last 5 years

Week 6: Discussion Question – Diagnosis Presentation

For discussion this week, students will post a presentation for review and discussion among other students. Please post your presentation by Thursday. You may use feedback from your peers to help improve the presentation, which will be then submitted to the assignment dropbox on Monday night. There will be two grades associated with this project; the weekly discussion grade and also the instructor’s grade of the presentation itself, in the assignment dropbox Please see the presentation assignment prompt for more details.

 

 

Expectations

Initial Post:

  • Due: Thursday, 11:59 pm PT
  • Length: 10-12 slides in length (excluding title and reference slides, with a maximum recording length of 20 minutes)
  • Format: PPT titled as follows:
  • Last name_DiagnosisPresentation1_mmddyyyy
  • Example: Billingsley_CholecystitisPresentation1_01172020
  • Citations: At least 6-7 high-level scholarly references in APA from within the last 5 years

Week 7: Discussion Question – Health Promotion & Wellness or Clinical Goals & Evidence-Based Practice

Evaluate the Healthy People 2030 goals and summarize two guidelines for health screenings or modifiable risk factors that can be recommended by the advanced practice nurse. Reference and citations required.

Expectations

Initial Post:

  • Due: Thursday, 11:59 pm PT
  • Length: A minimum of 300 words, not including references
  • Citations: At least 4-5 high-level scholarly reference in APA from within the last 5 years

 

Week 8: Discussion Question – Reflection

 

Week 8: Discussion Question – Reflection

Of the 6 SOAP notes you submitted for this course and uploaded in Project Concert, which categories within the template below did you complete? For your personal use and tracking, please place dates in the boxes as you complete the SOAP notes (Do not include this information in your response to this prompt, this is for personal tracking only). This will help you visualize your progress, however, this is a supportive reflective activity and is not intended to replace or augment documentation of hours. The notes in Project Concert will be used to determine whether the program criteria are met.  Please continue to use this form in subsequent clinical courses.

Consider: Which categories (body systems) and which ages should you prioritize for program completion? Which areas have you finished? Of the minimum required pediatric categories (infant, child, teen), and maternal health, how many more do you still need to capture in your total clinical requirements (list each category)?

Response Instructions:

  • Complete the activity outlined in this prompt (Do not upload the template in your response)
  • Reflect on your completion of this activity and the considerations above. Template
  • Summarize a reflection that includes a de-identified description of a patient encounter you found memorable for this course.
  • What made it memorable and what might you do differently if you were to see that patient again?

Expectations

Initial Post:

  • Due: Thursday, 11:59 pm PT
  • Length: A minimum of 300 words, not including references
  • Citations: At least 4-5 high-level scholarly reference in APA from within the last 5 years

 

Summary Week 7 Clinical FNP 592 Evaluate the Healthy People 2030 goals and summarize two guidelines

Evaluate the Healthy People 2030 goals and summarize two guidelines for health screenings or modifiable risk factors that can be recommended by the advanced practice nurse. Reference and citations required.

Expectations Initial Post: Length: A minimum of 250 words, not including references Citations: At least one high-level scholarly reference in APA from within the last 5 years

SOAP Note Week Two

 

United States University

FNP592: Common Illnesses Across the Lifespan

Dr. Theresa Gress

October 1, 2020

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SOAP Note Week Three

ID: Mickey Mouse, DOB 1/1/2000, age 20, white Hispanic male presents to the clinic unaccompanied and appears to be a reliable historian.

S:

CC: “Cough, runny nose, and sore throat x 7 days”

 

HPI: New Asian male patient 28 yo presents to the clinic unaccompanied, complaining of non-productive cough, runny nose and sore throat x 7 days (1/7/2020). Currently somewhat controlling symptoms with Dayquil and Nyquil. Cough mild, worsened when laying flat. Highest temp at home 99 degrees. Patient wondering if he needs antibiotics. Rates pain in throat as 4/10, described as “aching, swallowing makes it worse”, relieved by Dayquil/nyquil. Denies headache, denies sick contacts or recent travel. Denies feeling worse outdoors or seasonally. He is a reliable historian

PMH:

Allergies: No known drug allergies. Strawberries (rash), seasonal allergies Childhood: Asthma until high school, chickenpox at age 2

Surgical: Tonsillectomy (1998), Wisdom Teeth Removal (2005)

Medications: None

Vaccinations: received childhood vaccines, Last flu shot given Oct 2019.

Denies psychiatric history.

Social History:

Denies tobacco/e-cigarette use. Admits to occasional once every 2-3 months alcohol use – last drink

2 months ago, Engaged, works in IT, Hobbies include archery.

Family History:

Mother died age 60-Diabetes II Sister 42yo living -HTN Maternal Grandma died age 67- Dementia

ROS:

General: No weight change, weakness, fatigue, fevers..

Eyes: no vision change, corrective lenses, pain redness, excessive tearing, double vision, blurred vision, or blindness. EarsNose/Throat/mouth: no hearing change, tinnitus, earaches, infection, discharge. POSITIVE FOR RHINORRHEA. No sinus pain or epistaxis. POSITIVE FOR SORE THROAT, HOARSE VOICE. No bleeding gums, dentures, sore tongue, dry mouth. Last dental exam was 4 months ago.

C/V: Denies chest pain, palpitations. Pulmonary: POSITIVE FOR NON-PRODUCTIVE COUGH, negative hemoptysis, dyspnea, wheezing, pleuritic pain Neuro: No headache, dizziness, focal numbness/weakness, nausea, vomiting.

Lymph: Denies swollen lymph nodes in neck.

Allergy/immunology: Denies seasonal allergies or allergy to pets, pollen or other. Denies frequent illness.

O:

VS: T – 98 P – 80 R – 16 BP – 128/72 O2 sat – 99% – 4/10 pain in throat. Wt: 205 Ht: 72 in BMI: 27.8

Skin: Natural in color, warm, smooth and dry. Good skin turgor, no lesions, rashes, ecchymosis or moles. Nails without clubbing or cyanosis.

HEENT: Ears: pinna clean, no exudate noted. TM intact and pearly gray with cone of light bilat. Nose: nasal mucosa pink and moist. Inferior turbinates slightly reddened bilat. Nares patent bilat. No sinus pain upon palpation. Septum midline. Throat: oral mucosa pink and moist, tongue mobile without lesions, tonsils absent. Posterior pharynx with erythema but no cobblestone appearance. Neck: non-tender cervical area, no lymph nodes palpable. Non-enlarged thyroid palpated. Trachea midline. Neuro: Alert and oriented x 4. Cardio: RRR. Crisp S1 S2 without clicks or murmurs.

Thorax and lungs: Thorax is symmetric with good expansion. Respirations are even and unlabored. No use of accessory muscles, stridor, grunting, or nasal flaring. Lungs CTA Bilaterally.

(***notice not all systems are in the PE when doing a focused exam on a problem)

 

A:

Differential DDX: INCLUDE AT LEAST 3 DIFFERENTIALS

1. Viral pharyngitis – most likely as evidenced by sore throat, cough, no fever (Stead, 2019). (←←←←←that is a practice treatment guideline)

2. Strep Throat – not as likely; no fever and 7 days duration, age not as consistent with this dx

3. Allergic rhinitis – no report of sx increasing with outdoor activity or exposure to allergens, sx with sore throat are less likely for allergies.

 

DX: Viral pharyngitis

 

P:

In house throat swab for rapid strep – negative.

Continue to rest and drink lots of fluids (Cash & Glass, 2017; Stead, 2019).

Continue OTC Dayquil/Nyquil PRN per directions on the box – Safe dosing discussed, sedation may occur with Nyquil, avoid driving or operating heavy machinery after taking.

Encourage tea with honey and lemon to help with cough and sore throat.

Gargle with warm salt water 2-3 times a day for 30 sec, swish and spit.

Do not drink alcohol while taking these medications.

Cover mouth when coughing, do not drink after other people (Cash & Glass, 2017).

Return to office in 3-4 days if symptoms do not improve, worsen, or get better and then again get worse (Cash & Glass, 2017). Call 911 or go to ER for trouble breathing or any other emergent concern (Stead, 2019).

 

 

 

References:

 

Cash, J. & Glass, C. (2017). Family practice guidelines. New York, NY. Springer.

 

Stead, W. (2019). Symptomatic treatment of acute pharyngitis in adults. In L. Kunnis

(Ed.). UpToDate Retrieved February 12, 2020 from:

https://www.uptodate.com/contents/symptomatic-treatment-of-acute-pharyngitis-

in-adults

SOAP Note Week Eight – Pediatric UTI

Carla J. Aldaz, RN, BSN

United States University

FNP592: Common Illness Across the Lifespan

Professor Gryan Garcia

June 28, 2021

 

 

SOAP Note Week Eight – Pediatric UTI

ID: S.U., DOB: 11/16/2007, 14-year-old Caucasian Female present to the clinic with her Mother. The Patient and Mother appear to be reliable historians.

S: CC: “Cloudy, foul-smelling pee, and is burning and painful x 3 days.” HPI: S.U. is a 14-year-old Caucasian Female that presents to the clinic with her Mother. The Mother states that the child has frequently been urinating, and the urine is cloudy and foul- smelling. The child expresses that it is uncomfortable to urinate as it has a burning sensation. The child states that it started 3 days ago after she got home from swim camp. She denies blood in the urine, vaginal discharge, or irritations along with SOB, flank pain, or fever. The patient rates pain 7/10 when urinating.

PMH: Gestational age 40 weeks delivery was vaginal, Met growth and developmental milestones, no phycological or social concerns. The Patient is with optimal physical, social, and mental health. Allergies: No known drug allergies, No food allergies, No seasonal allergies Surgical: Wisdom Teeth 2020 Medication: None Vaccinations: Up to date on childhood vaccines, Flu shot November 2020 Social History: The Patient lives with her Mother: Father, and older brother in a single-level home. The Patient is just completed 8th grade and will be starting her freshman year. The Patient is a single heterosexual that is not sexually active. The Patient babysits 2x a week and plays soccer. Father is a Dentist, and Mother is a Hairstylist. Menstrual cycle started at age 12 and is regular. Her last menstrual period was two weeks ago. The patient eats a well-balanced diet; No guns are in the home, and Patient feels safe.

Family History: Maternal Grandparents-Grandmother-68 Hx: Glaucoma Grandfather-60 diseased- Lung Cancer Paternal Grandparents- Grandmother- 65 No medical history healthy Grandfather-66 Hx: Hypertension, DMII Father- 39 Hx: Hypertension Mother-38 Hx: Hypothyroid Brother- 16 Healthy no medical history

ROS:

Constitution: Denies weakness, fatigue, weight loss, or fever at this time HEENT: Denies dizziness, vision impairment, or headache, Denies hearing loss ear pain or discharge, Denies loss of smell, congestion or sinus pain, Denies sore throat, sores, lesions, or bleeding gums Pulmonary: Denies SOB, dyspnea on exertion, cough, wheezing, and no history of Asthma or seasonal allergies Cardiovascular: Denies Chest pain, palpations, no murmurs, syncope, or swelling Skin: Denies itching, dryness, loss of hair, rashes, or changes in nail texture Gastrointestinal: Denies nausea, vomiting, change in appetite, or bowel

 

 

movements Genitourinary: Complaints of frequent urination, burning and 7 out of 10 pain during urination, Report cloudy, foul-smelling urine, Denies blood in the urine or vaginal discharge Musculoskeletal: Denies muscle pain or aches, No joint deformities or issues with gait Neurologic: Denies paresthesia, numbness or tingling Psychiatric: Denies depression or suicidal ideation Hematologic: Denies bruising, bleeding history of anemia or fatigue

Allergy/immunologic: Denies allergies or immunologic compromise

O: Vital Signs: Temp: 98.4 HR: 80 RR:17 BP:117/68 O2: RA 100% Wt: 125 Ht: 63in. BMI:22.1 Pain Scale: 7/10- During urination

Physical Exam: Appearance: Happy pleasant, and cooperative teenage female in no acute distress. Alert and oriented x4. Patient and Mother engaged in conversation; Patient maintains eye contact and answers each interview and examination question. HEENT: Normocephalic Normal hair distribution, No visual or hearing impairment, PERRLA, TM intact and pearly gray, Nasal mucosa pink and moist, oral mucosa pin and moist neck non- tender trachea midline, no lymph node swelling or tenderness, good dentition, no lesions or sores noted. Pulmonary: Lungs symmetric with equal rise and fall clear to auscultation bilaterally, no rales, rhonchi, or wheezing noted Cardiovascular: Regular Heart Rate S1 and S2 upon auscultation, no murmurs, gallops, rubs, heaves, or lifts noted Skin: Natural in color, warm to touch, smooth and dry, good skin turgor, no rashes, lesions, bruising, or cyanosis noted. Abdomen: Nontender, soft, normoactive bowel sound in all 4 quadrants Genital-Urinary: Bladder not distend on palpation, denied vaginal discharge, frequent, painful burning sensation with urination No vaginal exam was performed. Musculoskeletal: Full ROM w/ 5/5 strength bilaterally in upper and lower extremities. No joint or muscle pain or tenderness noted, steady gait Neurological: Motor function intact, no weakness or tremors Psychiatric: Affect and mood stable

A: Differential DDX:

• Urinary Tract Infection N39.0: Patient complains of frequent urination with burning sensation while urinating for 3 days after returning home from swimming camp. The Patient states 7 out of 10 pain during urination. In addition, the Patient reports cloudy, foul-smelling urine, Denies blood in urine, vaginal discharge, or fever.

• Vaginitis N77.1: Patient has painful urination, and foul-smelling odor in urine R/O patient is not sexually active and does not have any vaginal bleeding, itching, or discharge (Dains & Ciofu Bauman, 2020).

• Urethritis N34.1: Patient has painful, frequent urination R/O patient is not sexually active and does not have any vaginal itching, irritation, or discharge (Dains & Ciofu Bauman, 2020).

FINAL DX: Urinary Tract Infection

 

 

P: Diagnostic:

U/A: Urine dipstick specimen (Hollier, 2021).

Tested Sample Showed: Urine dipstick specimen yielded a small amount of cloudy urine, positive for leukocyte esterase, and nitrite test.

Pharmacological Treatment: • Current treatment recommendations for UTI therapy for young women without

comorbidities is a short course of 3-7 days of antibiotics (Hollier, 2021). • Sulfamethoxazole/ Trimethoprim (Bactrim) 160mg PO BID for 3 days (Hollier, 2021).

Non-Pharmacologic Treatment Plan:

• Education: Good hydration to prevent further health complications like kidney stones while taking Bactrim (Dains & Ciofu Bauman, 2020).

• Education on medication compliance: Instruct patient to take medication as prescribed and not take extra medication for a missed dose. Avoid exposure to sunlight and tanning beds as Bactrim can cause sensitivity to sunlight (Dains & Ciofu Bauman, 2020).

• Education to avoid hygiene sprays and douches (Dains & Ciofu Bauman, 2020). • Education on proper wiping from front to back(Dains & Ciofu Bauman, 2020). • Education on the importance to not wear wet or tight underwear to reduce risk of

infection/Instruct patient to change out of wet swimming suit after swimming (Dains & Ciofu Bauman, 2020).

• Education on Cranberry juice to help reduce recurrent infections (Dains & Ciofu Bauman, 2020).

Follow-up: 1 week to monitor signs and symptoms instruct patient and Mother to contact office increased signs and symptoms, shortness of breath, nausea, vomiting, diarrhea, dark urine, dizziness, fever or skin reaction.

 

 

Reference

Dains, J. E., Ciofu Bauman, L., & P. (2020). Advanced Health Assessment and Clinical Diagnosis

in Primary Care (6th ed.). St. Louis, MO: Elsivier.

Hollier, A. (2021). Clinical guidelines in primary care (4th ed.). Advanced Practice Education

Associates. ISBN-978-1

 

  • SOAP Note Week Eight – Pediatric UTI
  • SOAP Note Week Eight – Pediatric UTI
  • PMH:
  • Social History:
  • Family History:
  • ROS:
  • O:
  • Physical Exam:
  • A:
  • Pharmacological Treatment:
  • Non-Pharmacologic Treatment Plan:

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