NSG 6020 Week 9 SOAP RH – MS with Contractions

NSG 6020 Week 9 SOAP RH – MS with Contractions

NSG 6020 Week 9 SOAP RH – MS with Contractions

Name: RH       Age: 68                       Gender: Female          Wgt: 151 (-3)  BMI 26.4

Code Status: FC          Pulse: 68         BP: 127/76      O2: 96% RA   RR: 18 Temp: Afebrile Allergies: PCN and Latex

CC: Wellness Visit (Comprehensive)

HPI: MS with contractions is her predominant diagnosis (Primary)

PMHx: diabetes, MS w/contractions, neurogenic bladder, GERD, CKD Stg II, HLD, Constipation, Recurrent UTI, Anxiety and Depression (MDD was mild at mother’s death)

SoHx: Patient is a residence of this facility and has been since 2005. Until recently, she shared a room with her mother and was her caregiver prior to reaching the need for long term care herself. She and her mother shared a room in the facility until July 2018 when her mother passed. MDD flared at that time and PRN Ativan was given for a short time with success. She no longer requires and has refused Cymbalta. NSG 6020 Week 9 SOAP RH – MS with Contractions.

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Medications: Baclofen 20 mg q day; K+ 20 mEq daily; Belsomra 10 mg HOS, atorvastatin 20 mg HOS; Claritin 10 mg HOS; flagyl 500 mg bid; hydrocodone 5/325;

Subjective/ROS:

General: denies; Resp: denies; Cardio: denies; GI: denies; GU denies; MSK: denies; Neuro: denies; Skin/Breast: denies; Psych: denies; lymph/heme: denies

Objective/Assessments:

General: appetite satisfactory, patient awake and alert, agreeable to meeting us, smiling, skin warm and dry. NSG 6020 Week 9 SOAP RH – MS with Contractions.

Respiratory: clear in all lung fields, no wheezes, no rhonchi

Cardiologist: Sinus rhythm 68-70 no murmurs, no bruits/thrills

GI: BS + all 4 quadrants

GU: suprapubic catheter is dry and has a drain sponge, urine clear,

MSK: BLE weakness with minimal edema, BUE good strength, Left trochanter wound with dressing

Neuro: No loss of consciousness, seizures, dizziness, or syncope. NSG 6020 Week 9 SOAP RH – MS with Contractions

NSG 6020 Week 10 Discussion

The discussion assignment provides a forum for discussing relevant topics for this week based on the course competencies covered.

For this assignment, go to the Discussion Area and post a response to the given question in the Discussion Area by the due date assigned.

To support your work, use your course and text readings and also use the South University Online Library. As in all assignments, cite your sources in your work and provide references for the citations in APA format.

Start reviewing and responding to the postings of your classmates as early in the week as possible. Respond to at least two of your classmates’ initial postings. Participate in the discussion by asking a question, providing a statement of clarification, providing a point of view with a rationale, challenging an aspect of the discussion, or indicating a relationship between two or more lines of reasoning in the discussion. Cite sources in your responses to other classmates. Complete your participation for this assignment by the end of the week.

Assignment

Complete only the History, Physical Exam, and Assessment sections of the iHuman case: Bebe Babbitt V4 PC

Click here for information on how to access and navigate iHuman. NSG 6020 Course Discussion Assignment Papers.

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Discussion Question 1

Based on your performance and the expert feedback in your HISTORY collection, describe two missed questions and your understanding of why they were important to collect for this case history. Use specific references from your text to explain.

Discussion Question 2

Based on your performance and the expert feedback in your PHYSICAL EXAM collection, describe two errors in your exam performance or documentation. Use specific references from your text to explain the importance of these findings in correct assessment of this client.

Discussion Question 3

Based on your performance on the PHYSICAL EXAM collection, describe one key finding that you included in your list and describe a specific physical exam that you can perform at the point-of-care to further evaluate the finding. Use specific references from your text.

Discussion Question 4

Based on your performance and the expert feedback in your ASSESSMENT identification of problem categories, choose one missed/incorrect category and use specific references from your text to explain the importance of this category in arriving at correct differential diagnoses for this client.

Discussion Question 5

Based on your performance and the expert feedback in your ASSESSMENT of differential diagnoses, describe one incorrect/missed differential diagnosis and use specific references from your text to support the inclusion of the diagnosis for this client.

Week 5 SOAP Note Assignment

SOAP Note

Each week you are required to enter your patient encounters into CORE. Your faculty will be checking to ensure you are seeing the right number and mix of patients for a good learning experience. Beginning in Week 5, you will need to include one complete SOAP note each week through Week 9 for a total of 5 complete SOAP notes for this course using this SOAP note template. The SOAP note should be related to the content covered in this week, and the completed SOAP note should be submitted to the Submissions Area. When submitting your note, be sure to include the reference number from CORE where you entered this specific patient’s case entry.

Submission Details:

By the due date assigned, enter your patient encounters into CORE and complete at least one SOAP note in the template provided.

Name your SOAP note document SU_NSG 6020_W5_A2_LastName_FirstInitial.doc.

Include the reference number from CORE in your document.

Submit your document to the Submissions Area by the due date assigned.

Week 6 SOAP Note Assignment

SOAP Note

Each week you are required to enter your patient encounters into CORE. Your faculty will be checking to ensure you are seeing the right number and mix of patients for a good learning experience. Beginning in Week 5, you will need to include one complete SOAP note each week through Week 9 for a total of 5 complete SOAP notes for this course using this SOAP note template. The SOAP note should be related to the content covered in this week, and the completed SOAP note should be submitted to the Submission Area. When submitting your note, be sure to include the reference number from CORE where you entered this specific patient’s case entry.

Submission Details:

By the due date assigned, enter your patient encounters into CORE and complete at least one SOAP note in the template provided.

Name your SOAP note document SU_NSG 6020_W6_A4_LastName_FirstInitial.doc.

Include the reference number from CORE in your document.

Submit your document to the Submissions Area by the due date assigned. NSG 6020 Week 9 SOAP RH – MS with Contractions.

Week 6 Physical Exam Video and Write Up Assignment

Complete Health History and Physical Assessment Write-Up Presentation

This assignment consists of complete head to toe physical while being videoed. You will also need to complete a written assignment of your findings. Review the Expanded rubric to note how you will be graded on this assignment.

Week 7 SOAP Note Assignment

Each week you are required to enter your patient encounters into CORE. Your faculty will be checking to ensure you are seeing the right number and mix of patients for a good learning experience. Beginning in Week 5, you will need to include one complete SOAP note each week through Week 9 for a total of 5 complete SOAP notes for this course using this SOAP note template. The SOAP note should be related to the content covered in this week, and the completed SOAP note should be submitted to the Submissions Area. When submitting your note, be sure to include the reference number from CORE where you entered this specific patient’s case entry.

Submission Details:

By the due date assigned, enter your patient encounters into CORE and complete at least one SOAP note in the template provided.

Name your SOAP note document SU_NSG 6020_W7_A3_LastName_FirstInitial.doc.

Include the reference number from CORE in your document.

Submit your document to the Submissions Area by the due date assigned.

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Week 8 SOAP Note Assignment

SOAP Note

Each week you are required to enter your patient encounters into CORE. Your faculty will be checking to ensure you are seeing the right number and mix of patients for a good learning experience. Beginning in Week 5, you will need to include one complete SOAP note each week through Week 9 for a total of 5 complete SOAP notes for this course using this SOAP note template. The SOAP note should be related to the content covered in this week, and the completed SOAP note should be submitted to the Submissions Area. When submitting your note, be sure to include the reference number from CORE where you entered this specific patient’s case entry.

Submission Details:

By the due date assigned, enter your patient encounters into CORE and complete at least one SOAP note in the template provided.

Name your SOAP note document SU_NSG 6020_W8_A3_LastName_FirstInitial.doc.

Include the reference number from CORE in your document.

Submit your document to the Submissions Area by the due date assigned.

Week 9 SOAP Note Assignment

SOAP NOTE

Each week you are required to enter your patient encounters into CORE. Your faculty will be checking to ensure you are seeing the right number and mix of patients for a good learning experience. Beginning in Week 5, you will need to include one complete SOAP note each week through Week 9 for a total of 5 complete SOAP notes for this course using this SOAP note template. The SOAP note should be related to the content covered in this week, and the completed SOAP note should be submitted to the Submissions Area. When submitting your note, be sure to include the reference number from CORE where you entered this specific patient’s case entry.

Submission Details:

By the due date assigned enter your patient encounters into CORE and complete at least one SOAP note in the template provided. NSG 6020 Week 9 SOAP RH – MS with Contractions.

Name your SOAP note document SU_NSG 6020_W9_A3_LastName_FirstInitial.doc.

Include the reference number from CORE in your document.

Submit your document to the Submissions Area by the due date assigned.