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Week 2 Project 2 SOAP Note and eMedley Entries

Week 2 Project 2 SOAP Note and eMedley Entries

Week 2 Project 2 SOAP Note and eMedley Entries

Each week, you are required to enter your patient encounters into eMedley. Your faculty will be checking to ensure you are seeing the right number and mix of patients for a good learning experience. You will also need to include a minimum of one complete SOAP note using this template . The SOAP note should be related to the content covered in this week, and the completed note should be submitted to the Submissions Area. When submitting your note, be sure to include the reference number from eMedley.

Submission Details:

  • By the end of the week enter your patient encounters into eMedley and complete at least one SOAP note in the template provided.
  • Name your SOAP note document SU_NSG6440_W2_SOAPLastName_FirstInitial.doc.
  • Include the reference number from eMedley in your document.
  • Submit your document to the Submissions Area by the due date assigned.

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NSG 6440 Week 6 Discussion

Discussion:

This week’s content discussed common psychiatric disorders in the Adult and Older Adult client.  Often times a secondary diagnosis is masked due to their psychiatric disorder.  Review the following case study and answer the following questions.

Mr. White is a 72-year-old man, with a history of hypertension, COPD and moderate dementia, who presents with 4 days of increased confusion, nighttime restlessness, visual hallucinations, and urinary incontinence. His physical exam is unremarkable except for tachypnea, a mildly enlarged prostate, inattentiveness, and a worsening of his MMSE score from a baseline of 18 to 12 today.

Mr. White’s presentation is most consistent with an acute delirium (acute change in cognition, perceptual derangement, waxing and waning consciousness, and inattention).

  1. What is the most likely diagnosis to frequently cause acute delirium in patients with dementia?
  2. What additional testing should you consider if any?
  3. What are treatment options to consider with this patient?

Submission Details:

  • Post your response to the Discussion Area by the due date assigned. Respond to atleast two posts by the end of the week.