Nonpharmacologic Treatments and Alternative Therapies

Nonpharmacologic Treatments and Alternative Therapies

Nonpharmacologic Treatments and Alternative Therapies

Select a patient that you examined as a nurse practitioner student during the last three weeks of clinical on OB/GYN Issue. With this patient in mind, address the following in a SOAP Note 1 OR 2 PAGES :

Subjective: What details did the patient provide regarding her personal and medical history?

Objective: What observations did you make during the physical assessment?

Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority. What was your primary diagnosis and why?

Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management, including alternative therapies? Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters for this patient , as well as a rationale for this treatment and management plan.

Nonpharmacologic Treatments and Alternative Therapies

Very Important:  Reflection notes: What would you do differently in a similar patient evaluation?

Reference

Gagan, M. J. (2009). The SOAP format enhances communication. Kai Tiaki Nursing New Zealand, 15(5), 15.

Tharpe, N. L., Farley, C., & Jordan, R. G. (2013). Clinical practice guidelines for midwifery & Women’s health (4th ed.). Burlington, MA: Jones & Bartlett Publishers.

Chapter 6, “Care of the Well Woman Across the Life Span” ,“Care of the Woman Interested in Barrier Methods of Birth Control” (pp. 275–278)

Chapter 7, “Care of the Woman with Reproductive Health Problems”

“Care of the Woman with Dysmenorrhea” (pp. 366–368)

“Care of the Woman with Premenstrual Symptoms, Syndrome (PMS), or Dysphoric Disorder (PMDD)” (pp. 414–418)

Rights of Medication Administration

1. Right patient

• Check the name on the order and the patient.
• Use 2 identifiers.
• Ask patient to identify himself/herself.
• When available, use technology (for example, bar-code system).

2. Right medication

• Check the medication label.
• Check the order.

3. Right dose

• Check the order.
• Confirm appropriateness of the dose using a current drug reference.
• If necessary, calculate the dose and have another nurse calculate the dose as well.

4. Right route

• Again, check the order and appropriateness of the route ordered.
• Confirm that the patient can take or receive the medication by the ordered route.

5. Right time

• Check the frequency of the ordered medication.
• Double-check that you are giving the ordered dose at the correct time.
• Confirm when the last dose was given.

6. Right documentation

• Document administration AFTER giving the ordered medication.
• Chart the time, route, and any other specific information as necessary. For example, the site of an injection or any laboratory value or vital sign that needed to be checked before giving the drug.

7. Right reason

• Confirm the rationale for the ordered medication.  What is the patient’s history?