Fluent Essays

These are seperate assignemnt. I will be providing you with patient information for the comprehensive soap noteWK 9Part 2 :Discussion: Nonadherence to Lifestyle Changes During PregnancyAfter identifying potential health risks for pregnant patients, providers often recommend behavior changes in lifestyle choices such as drug use, alcohol consumption, dietary habits, and environmental exposures. Even with provider recommendations and patient education programs, some patients still struggle to adhere to recommended lifestyle changes during pregnancy, posing health risks for both the mother and child. In your role as the provider, you must be able to recognize signs of nonadherence to recommended lifestyle changes because not all patients will be forthcoming with the struggles they may be experiencing. Management plans are only successful if patients’ individual needs are recognized and met, so provider-patient collaboration is essential for mitigating nonadherence issues. For this Discussion, consider implications of nonadherence to recommended lifestyle changes and potential management strategies for pregnant patients.To prepare:Review the “During Pregnancy” article in this week’s Learning Resources. (https://www.acog.org/Clinical-Guidance-and-Publica...)Think about the health promotion topic that you selected for the Week 8 Discussion (i.e., smoking, drinking, taking drugs, eating habits, and caring for pets).With the topic you selected in mind, consider early signs and symptoms that might indicate a patient’s nonadherence to recommended lifestyle changes during pregnancy. Think about the impact of nonadherence on the fetus and the patient.Reflect on treatment and management strategies for patients presenting with signs and symptoms of nonadherence to recommended lifestyle changes. Post an explanation of signs and symptoms that might indicate a pregnant patient’s nonadherence to recommended lifestyle changes related to the topic you selected. Explain the impact of nonadherence to these lifestyle recommendations on the fetus and the patient. Then, explain treatment and management strategies for patients presenting with signs and symptoms resulting from their nonadherence.Assignment 1: Application – Comprehensive Well-Woman Exam When completing practicum requirements in clinical settings, you and your Preceptor might complete several patient assessments in the course of a day or even just a few hours. This schedule does not always allow for a thorough discussion or reflection on every patient you have seen. As a future advanced practice nurse, it is important that you take the time to reflect on a comprehensive patient assessment that includes everything from patient medical history to evaluations and follow-up care. For this Assignment, you begin to plan and write a comprehensive assessment that focuses on one female patient from your current practicum setting.To prepareReflect 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, treatment and management plan, as well as education strategies and follow-up care.To completeWrite an 8- to 10-page comprehensive assessment that addresses the following:Age, race and ethnicity, and partner status of the patientCurrent health status, including chief concern or complaint of the patientContraception 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 systemsPhysical examLabs, tests, and other diagnosticsDifferential diagnosesManagement plan, including diagnosis, treatment, patient education, and follow-up careThere should be an acute problem that leads to a main diagnosis followed by a minimum of 3 differentials. Each of these are to be supported with information that would rule in or rule out the diagnosis (in paragraph form). References should be included in the information used to support your thought process. Also, a reflection piece is required. It should be detailed and insightful. References should be included as well when discussing what was learned . Share what you may do differently, why or why not? Are there any alternative therapies to consider? Anything you would change from the plan of care? https://class.content.laureate.net/7193526f68d12e6... comprehensive_soap_guidline.docx Unformatted Attachment Preview Guidelines for a Comprehensive History and Physical SOAP Note • Label each section of the SOAP note (each body part and system). • Do not use unnecessary words or complete sentences. • Use Standard Abbreviations SUBJECTIVE DATA (S): (information the patient/caregiver tells you). Includes all of the information the patient tells you. Identifying data: Initials, age, race, gender, marital status. Name of informant, if not patient. CHIEF COMPLAINT (CC): The reason for this health care visit. A statement describing the symptom (s), problem, condition, diagnosis, physician-recommended return, or other factors that is the reason for this patient visit (even if they bring no specific problem). If possible, use the patients own words in quotation marks. HISTORY OF PRESENT ILLNESS (HPI): If the patient presents with specific problems, symptoms or complaints, a chronological description of the development of the patient’s present illness from the first sign of each symptom to the current visit is recorded using the elements of a symptom analysis. Those elements are: location: where it started, where it is located now quality: unique properties or characteristics of the symptom severity: intensity, quantity, or impact on life activities duration: length of episode timing: when symptom started, frequency (patients story of the symptom) context: under what conditions does it occur setting: under what conditions do the symptoms occur, activities that produce the symptoms alleviating and aggravating factors: what makes it better and/or worse; what meds have been taken to relieve symptoms, did the meds help or not; does food make symptoms worse or better, etc. associated signs and symptoms: Presence or absence of other symptoms or problems occurring with their complaint. Include pertinent negatives and information from the patients charts e.g. lab data or previous visit information. If the visit is for follow up of chronic conditions, a description of their health from the previous visit to the present to assess the status of their chronic conditions (this information should replace the symptom analysis in patients with chronic conditions). In the case of a well visit describe the patients usual health and summarize health maintenance needs and activities. PAST MEDICAL HISTORY (PMH): • Allergies • Current Medications: prescription and over the counter • Age/health status • Appropriate immunization status • Previous screening tests result • Dates of illnesses during childhood may not be very important in adults exceptions may include rheumatic fever or chronic illnesses continuing into adulthood. • Major adult illnesses (include history of diabetes, hypertension, gastrointestinal diseases, pulmonary disease, cardiovascular disease, cancer, tuberculosis, STIs, HIV/AIDS, gynecological or urological problems, drug and/or alcohol abuse, and psychiatric illness. ) • Injuries • Hospitalizations (reason, hospital, attending physician? if known • Surgeries (include hospital and year) FAMILY HISTORY (FH): Age and current health status or age at death and cause of death of each family member (parents, siblings and children) is recorded. Occurrence within the family of illnesses of an environmental, genetic, or familial nature are recorded in family history. Ask about the presence in the family of any of the following conditions: Asthma, glaucoma, myocardial infarctions, heart failure, hypertension, cancer, tuberculosis, diabetes, kidney disease, hemophilia, sickle cell trait or disease, psychiatric diseases, alcoholism allergies, family violence, Mental retardation, epilepsy, congenital abnormalities. . Record any specific diseases related to problems identified in CC, HPI or ROS. SOCIAL HISTORY (SH): Record important life events: marital status, occupational history, military service, level of education. Life style, current health habits (may be here or in ROS): exercise, diet, safety (smoke alarms, seatbelts, firearms, sports), living arrangements, hobbies, travel. Religious preference relevant to health, illness, or treatment. Habits: use of drugs, alcohol, and tobacco Resources: resources to pay for care, insurance, worries about cost of care, history of postponing care. REVIEW OF SYSTEMS (ROS): There are 14 systems for review. Record a summary for each system. Unexpected or positive findings need complete symptom analysis. (1) Constitutional symptoms- Overall health, weight gain or loss, ideal weight, fever, fatigue, repeated infections, ability to carry out activities of daily living. (2) Eyes- eye care, poor eyesight, double or blurred vision, use of corrective lenses or medications, redness, excessive tearing, pain, trauma, date and results of last vision screening or eye exam (3) Ears, nose, mouth and throat- Ears: hearing acuity, exposure to high noise level, tinnitus, and presence of infection or pain, vertigo, use of assistive hearing device. Nose: sense of smell, discharge, obstruction, epistaxis, sinus trouble. Mouth and teeth: use of oral tobacco or smoking cigarettes, last dental exam date and result, pattern of brushing and use of dental floss and fluoride toothpaste, dentures, bleeding of gums, sense of taste, mouth odor or ulcers, sore tongue. Throat: sore throat, hoarseness, dysphagia. (4) Cardiovascular- Exercise pattern to maintain cardiovascular health. History of abnormal heart sounds (including murmur), chest pains, palpitations, dyspnea, activity intolerance, usual blood pressure, ECG, (date, reason), cholesterol level (date), edema, claudication, varicose veins. (5) Respiratory- Exposure to passive smoke, History of respiratory infections, usual self- treatment, cough, last chest x-ray (date, result), exposure to TB and last TB skin test (date and result), difficult breathing, wheezing, hemoptysis, sputum production (character, amount), night sweats. (6) Gastrointestinal- dietary pattern, fiber, fat, in diet, use of nutritional supplements (vitamins, herbs), heartburn, epigastric pain, abdominal pain, nausea and vomiting, food intolerance, flatulence, diarrhea, constipation, usual bowel pattern, change in stools, hemorrhoids, jaundice. (7)Genitourinary- Nocturia, dysuria, incontinence, sexual practices, sexual difficulty, venereal disease, history of stones. Men: slow stream, penile discharge, contraceptive use, self-testicular exam. Women: onset, regularity, dysmenorrhea, intermenstrual discharge or bleeding, pregnancy history (number, miscarriages, abortions, duration of pregnancy, type of delivery, complications) menopause (if present, use of hormone replacement therapy), last menstrual period (LMP), contraceptive use, last pap smear (date and result), intake of folic acid. (8) Musculoskeletal- Exercise pattern, use of seatbelts, use of safety equipment with sports, etc., neck pain or stiffness, joint pain or swelling, incapacitating back pain, paralysis, deformities, changes in range of motion of activity, screening for osteoporosis, knowledge of back injury/pain prevention. (9) Integumentary (skin and/or breast)- use of skin protection with sun exposure, self examination practices in assessing skin, general skin condition and care, changes in skin, rash, itching, nail deformity, hair loss, moles, open areas, bruising. Breast: practice of self-breast exam, lumps, pain, discharge, dimpling, last mammogram (date and result). (10) Neurologic- muscle weakness, syncope, stroke, seizures, paresthesias, involuntary movements or tremors, loss of memory, severe headaches. I (11) Psychiatric- nightmares, mood changes, depression, anxiety, nervousness, insomnia, suicidal thoughts, potential for exposure to violence I (12) Endocrine- Thyroid problems, cold or heat intolerance, polydipsia, polyphagia, polyuria, changes in skin, hair or nail texture, unexplained weight change, changes in facial or body hair, change in hat or glove size, use of hormonal therapy. (13) Hematologic/lymphatic- bruising, unusual bleeding, fatigue, history of anemia, last HCT and result, history of blood transfusions, swollen and/or tender glands, (14) Allergic/immunologic- Seasonal allergies, previous allergy testing, potential for exposure to blood and body fluids, immunized for Hep B, immunosuppression in self or family member, use of steroids. OBJECTIVE DATA: A concise report of physical exam findings. Systems: (there are 12 systems for examination) 1. Constitutional (VS: Temp, BP, pulse, HT & WT); A statement describing the patient general appearance 2. Eyes 3. Ear, Nose, Throat 4. Cardiovascular 5. Respiratory 6. Gastrointestinal 7. Genitourinary 8. Musculoskeletal 9. Integument /lymphatic pertaining to each location 10. Neurologic 11. Psychiatric 12. Hematologic/ immunologic Results of any diagnostic testing available during patient visit. ASSESSMENT (A): • List and number the possible diagnoses (problems) you have identified. These diagnoses are the conclusions you have drawn from the subjective and objective data. • Diagnosis must be codable (CPT codes). • Provide adequate information to justify ordering additional data (lab, x-ray, etc.). • Do not write that a diagnosis is to be ruled out. State the working definitions (symptoms, probable diagnoses) of patient problems in the following areas: 1. Health maintenance 2. Acute self-limited problems 3. Chronic health problems In cases where the diagnosis is already established, indicate whether the diagnosis has the following characteristics: improved, wellcontrolled, resolving, resolved, inadequately controlled, worsening or failing to change as expected. Note: Inadequately controlled chronic conditions should have a possible etiology written (e.g. exacerbation, progression, side effects of treatment) if known. PLAN (P): (The plan should be discussed with and agreed on by the patient.) The treatment plan includes a wide range of management actions: • Laboratory test • Consultation requested and justification • Medications prescribed (name, dose, route, amount, refills) • Appliances prescribed • Life style modifications: Diet, activity modification, etc • Patient education and patient responsibilities (e.g. keeping food diary, or BP record). • Patient counseling related to: lab/ diagnostic results, impression or recommendations • Family education. • Details concerning coordination of care: arranging and organizing patients care with other providers and agencies. • Follow-up should be specified with time (in days, weeks, month) and/or circumstances of return or noted as PRN. Note: Number the plan to correlate with the problem list in the Assessment. ... Purchase answer to see full attachment