Soap Note For Older Adult Nursing Home Patient

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Question Description

Hello follow instruction, please can you use these ICD-10 Codes and diagnosis to make up 10 Soap notes with each of them for older adult patients or residents age 50 year old and up currently living in a Nursing Home Facility or Long Term Care Patients. Below is a sample of what to include in the notes how to do the soap notes. Use different age, Vital sign, sex, Mental status, weight, inches, BMI, ECT…… and information for each soap notes.

This is the sample of what to include in the notes:

Location: Nursing Home

Mental Status

Age: From 50 year old and up 69 years

Sex: Female and male

Height:

Weight: in LBS

BMI

Temperature:

Pulse:

Blood pressure:

Respiratory rate:

SpO2: on room air

Allergies:

Chief complaint:

HPI:

Past Medical History:

Immunization.

Rx (medications

FHx (family history):

Smoking

SHx (social history) SHx (social history)

Plan

Preventive Health:

Teaching

10) M62.81 Muscle weakness (generalized)

R26.2 Difficulty in walking, not elsewhere classified

Congestive heart failure, unspecified I50.20

I50.21 Acute systolic (congestive) heart failure

I50.22 Chronic systolic (congestive) heart failure

I50.23 Acute on chronic systolic (congestive) heart

failure

I50.30 Unspecified diastolic (congestive) heart

Failure

I50.31 Acute diastolic (congestive) heart failure

I50.32 Chronic diastolic (congestive) heart failure

I50.33 Acute on chronic diastolic (congestive) heart

failure

Disorders of the Veins and Arteries

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Assignment: Disorders of the Veins and Arteries

Advanced practice nurses often treat patients with vein and artery disorders such as chronic venous insufficiency (CVI) and deep venous thrombosis (DVT). While the symptoms of both disorders are noticeable, these symptoms are sometimes mistaken for signs of other conditions, making the disorders difficult to diagnose. Nurses must examine all symptoms and rule out other potential disorders before diagnosing and prescribing treatment for patients. In this Assignment, you explore the epidemiology, pathophysiology, and clinical presentation of CVI and DVT.

To Prepare

  • Review the section “Diseases of the Veins” (pp. 598-599) in Chapter 23 of the Huether and McCance text. Identify the pathophysiology of chronic venous insufficiency and deep venous thrombosis. Consider the similarities and differences between these disorders.
  • Select a patient factor different from the one you selected in this week’s Discussion: genetics, gender, ethnicity, age, or behavior. Think about how the factor you selected might impact the pathophysiology of CVI and DVT. Reflect on how you would diagnose and prescribe treatment of these disorders for a patient based on the factor you selected.
  • Review the “Mind Maps—Dementia, Endocarditis, and Gastro-oesophageal Reflux Disease (GERD)” media in the Week 2 Learning Resources. Use the examples in the media as a guide to construct two mind maps—one for chronic venous insufficiency and one for venous thrombosis. Consider the epidemiology and clinical presentation of both chronic venous insufficiency and deep venous thrombosis.

To Complete

APA format, Write a 2–page paper that addresses the following:

  • Compare the pathophysiology of chronic venous insufficiency and deep venous thrombosis. Describe how venous thrombosis is different from arterial thrombosis.
  • Explain how the patient factor you selected might impact the pathophysiology of CVI and DVT. Describe how you would diagnose and prescribe treatment of these disorders for a patient based on the factor you selected.
  • Construct two mind maps—one for chronic venous insufficiency and one for deep venous thrombosis. Include the epidemiology, pathophysiology, and clinical presentation, as well as the diagnosis and treatment you explained in your paper.

BY DAY 7

The Assignment is due.

Note: The School of Nursing requires that all papers submitted include a title page, introduction, summary, and references. The Sample Paper provided at the Walden Writing Center provides an example of those required elements (available at http://writingcenter.waldenu.edu/57.htm). All papers submitted must use this formatting.

  • From the Plagiarism Tools area, click the checkbox for I agree to submit my paper(s) to the Global Reference Database.

Application: Systems Theory

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Question Description

Assignment: Application: Systems Theory

As noted in the Learning Resources, systems theory provides a meaningful and beneficial means of examining challenges in health care organizations. To do this effectively, however, it is essential to assess allsystem components, as some may be relatively healthy while others are problematic.

For this Assignment, you apply systems theory to the examination of a problem in a department or a unit within a health care organization. (Note: You may use the same problem you identified for the Discussion as long as it meets the criteria for this assignment.)

To prepare:

  • Review the Meyer article, “Nursing Services Delivery Theory: An Open System Approach,” in this week’s Learning Resources. Focus especially on the information presented in Table 1 (p. 2831) and Figure 2 (p. 2833).
  • Reflect on your organization or one with which you are familiar. Within a particular department or unit in this organization, identify a problem the staff is encountering.
  • Using Table 1 in the Meyer article as a guide, analyze the department or unit, identifying inputs, throughput, output, cycles of events, and negative feedback. Consider whether the problem you have selected relates to input, throughput, output, cycles of events, and/or negative feedback.
  • Think about how you could address the problem: Consider what a desired outcome would be, then formulate related goals and objectives, and translate those goals into policies and procedures.
  • Research professional standards that are pertinent to your identified problem.
  • Reflect on the organization’s mission statement and values. In addition, consider how addressing this problem would uphold the mission and values, while improving the organizational culture and climate. (Depending on the organization you have selected, you may have explored these in the Week 1 Discussion.)

To complete:

BY DAY 7

Write a 3- to 5-page paper (page count does not include title and reference page) that addresses the following:

  • Describe a department or unit within a health care organization using systems theory terminology. Include a description of inputs, throughput, output, cycles of events, and negative feedback.
  • Describe the problem you identified within the department or unit using an open- systems approach, and state where the problem exists using the systems theory model (input, throughput, output, cycles of events, or negative feedback).
  • Based on this information, explain how you would address the problem as follows:
    • Formulate a desired outcome.
    • Identify goals and objectives that would facilitate that outcome.
    • Translate those goals and objectives into policies and procedures for the department or unit.
    • Describe relevant professional standards.
  • Explain how your proposed resolution to the problem would uphold the organization’s mission and values and improve the culture and climate.

The Assignment, Systems Theory, is due by Day 7 of Week 2.

Reminder: The School of Nursing requires that all papers submitted include a title page, introduction, summary, and references. The Sample Paper provided at the Walden Writing Centerprovides an example of those required elements. All papers submitted must use this formatting.

This Assignment is due by Day 7 of Week 2 (this week) and must be submitted through the Week 2 Assignment Link.

QUALITY OF WORK SUBMITTED:
THE EXTENT OF WHICH WORK MEETS THE ASSIGNED CRITERIA AND WORK REFLECTS GRADUATE LEVEL CRITICAL AND ANALYTIC THINKING.–

Excellent 27 (27%) – 30 (30%)

Good 24 (24%) – 26 (26%)

Fair 21 (21%) – 23 (23%)

Poor 0 (0%) – 20 (20%)

QUALITY OF WORK SUBMITTED:
THE PURPOSE OF THE PAPER IS CLEAR.–

Excellent 5 (5%) – 5 (5%)

Good 4 (4%) – 4 (4%)

Fair 3.5 (3.5%) – 3.5 (3.5%)

Poor 0 (0%) – 3 (3%)

ASSIMILATION AND SYNTHESIS OF IDEAS:
THE EXTEND TO WHICH THE WORK REFLECTS THE STUDENT’S ABILITY TO:

UNDERSTAND AND INTERPRET THE ASSIGNMENT’S KEY CONCEPTS.–

Excellent 9 (9%) – 10 (10%)

Good 8 (8%) – 8 (8%)

Fair 7 (7%) – 7 (7%)

Poor 0 (0%) – 6 (6%)

ASSIMILATION AND SYNTHESIS OF IDEAS:
THE EXTEND TO WHICH THE WORK REFLECTS THE STUDENT’S ABILITY TO:


APPLY AND INTEGRATE MATERIAL IN COURSE RESOURCES (I.E. VIDEO, REQUIRED READINGS, AND TEXTBOOK) AND CREDIBLE OUTSIDE RESOURCES.–

Excellent 18 (18%) – 20 (20%)

Good 16 (16%) – 17 (17%)

Fair 14 (14%) – 15 (15%)

Poor 0 (0%) – 13 (13%)

ASSIMILATION AND SYNTHESIS OF IDEAS:
THE EXTEND TO WHICH THE WORK REFLECTS THE STUDENT’S ABILITY TO:

SYNTHESIZE (COMBINES VARIOUS COMPONENTS OR DIFFERENT IDEAS INTO A NEW WHOLE) MATERIAL IN COURSE RESOURCES (I.E. VIDEO, REQUIRED READINGS, TEXTBOOK) AND OUTSIDE, CREDIBLE RESOURCES BY COMPARING DIFFERENT POINTS OF VIEW AND HIGHLIGHTING SIMILARITIES, DIFFERENCES, AND CONNECTIONS.–

Excellent 18 (18%) – 20 (20%)

Good 16 (16%) – 17 (17%)

Fair 14 (14%) – 15 (15%)

Poor 0 (0%) – 13 (13%)

WRITTEN EXPRESSION AND FORMATTING

PARAGRAPH AND SENTENCE STRUCTURE: PARAGRAPHS MAKE CLEAR POINTS THAT SUPPORT WELL DEVELOPED IDEAS, FLOW LOGICALLY, AND DEMONSTRATE CONTINUITY OF IDEAS. SENTENCES ARE CLEARLY STRUCTURED AND CAREFULLY FOCUSED–NEITHER LONG AND RAMBLING NOR SHORT AND LACKING SUBSTANCE.–

Excellent 5 (5%) – 5 (5%)

Good 4 (4%) – 4 (4%)

Fair 3.5 (3.5%) – 3.5 (3.5%)

Poor 0 (0%) – 3 (3%)

WRITTEN EXPRESSION AND FORMATTING

ENGLISH WRITING STANDARDS: CORRECT GRAMMAR, MECHANICS, AND PROPER PUNCTUATION–

Excellent 5 (5%) – 5 (5%)

Good 4 (4%) – 4 (4%)

Fair 3.5 (3.5%) – 3.5 (3.5%)

Poor 0 (0%) – 3 (3%)

WRITTEN EXPRESSION AND FORMATTING

THE PAPER FOLLOWS CORRECT APA FORMAT FOR TITLE PAGE, HEADINGS, FONT, SPACING, MARGINS, INDENTATIONS, PAGE NUMBERS, RUNNING HEAD, PARENTHETICAL/IN-TEXT CITATIONS, AND REFERENCE LIST.–

Excellent 5 (5%) – 5 (5%)

Good 4 (4%) – 4 (4%)

Fair 3.5 (3.5%) – 3.5 (3.5%)

Poor 0 (0%) – 3 (3%)

Nursing Care for Spiritual Distress: A Case Study

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Question Description

In the chapter titled “Spiritual Assessment” in your course textbook, there is a case study describing parents who have spiritual concerns related to their daughter’s health care. The nursing diagnosis of spiritual distress is made based on the assessment data. You are required to provide at least 1 short-term outcome and 3–4 nursing interventions that will aid in attaining the outcome.

Tasks:

Based on your own experience and from your readings in this course, the Argosy University online library resources, and the Internet, address the following:

Read the case study in the chapter “Spiritual Assessment” in your course textbook, and based on your understanding, answer the following questions:

  • What are the factors causing spiritual distress for this family?
  • What are the short-term outcomes related to the diagnosis of spiritual distress in this case study?
  • What are the priority nursing interventions in this situation?
  • What are your thoughts, feelings, and/or concerns related to caring for this family including why you think this self-reflection may be important as you provide nursing care?

Submission Details:

  • Write your initial response in a 2- to 3-page Microsoft Word document.
  • Your response should be thorough and address all components of the discussion question in detail. Include citations of all sources, where needed, according to the APA style. Demonstrate accurate spelling, grammar, and punctuation. Use this APA Citation Helper as a convenient reference for properly citing resources.

By the due date assigned, copy your response from your document and paste it in the Discussion Area. In addition, post your Microsoft Word document as an attachment. Through the end of the module, review and comment on at least two classmates’ responses.

Do the following when responding to your classmates:

  • Read your classmates’ responses.
  • Provide substantive comments by doing some or all of the following:
    • Contribute new, relevant information from course readings, websites, or other sources
    • Build on the remarks or questions of others
    • Share practical examples of key concepts from your professional or personal experiences
  • Respond to feedback on your posting and provide feedback to your classmates on their ideas.
  • Make sure your writing:
    • Is clear, concise, and organized
    • Demonstrates ethical scholarship in the accurate representation and attribution of sources
    • Displays accurate spelling, grammar, and punctuation

the discipline of nursing with the inclusion of nursing scholarly sources to substantiate the literature review.

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Question Description

Concept Analysis Paper

Description

In this paper you will demonstrate scholarly, graduate school level writing and critical analysis of existing nursing knowledge. Your final paper will be 7–10 pages (excluding title page and references), using APA format with at least 8–10 scholarly nursing sources of information.

Directions:

For your final submission, you will take a concept of interest to you and develop it into a final concept analysis paper. You may choose to apply your Unit 3 concept to this Assignment, or you may select another single word (concept) that you have wondered about or discovered in your readings.

The Unit 9 Assignment will focus solely upon the discipline of nursing with the inclusion of nursing scholarly sources to substantiate the literature review. Locate evidenced-based articles (based on research studies in nursing) that use the concept or discuss the concept.

For this paper you will:

  • Identify the concept and purpose for studying the concept.
  • Describe reasons for this concept being of interest to nursing and its body of knowledge.
  • Define the attributes of the concept and relevant uses.
  • Provide a summary of the concept as described in each article with examples of how the term was defined.
  • Provide the theoretical and operational definition of the concept based on the review of literature. (Theoretical is pure definition and operational is how it is used in practice.)
  • Apply the concept as it relates to your practice and how you will use this concept in the future.
  • Describe the value of these concept analyses to your understanding of nursing knowledge.

Describe the chosen theory, research, and practice guideline or standard. Provide citations for theory and practice guidelines.

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Question Description

Fundamentals of Nursing Models, Theories, and Practice discusses the theory-practice gap in detail in many chapters. As you’ve read throughout the course, there is ongoing discussion about the connection between theory and practice, and the application in day-to-day nursing activities. This assignment is designed to illustrate that although there may be a gap, other factors play an important role in decision-making and each aspect of theory, research, and practice experience are integral to well-rounded patient care.

Click the Paper tab for a link to Fundamentals of Nursing Models, Theories, and Practice and review Figure 1.4 Correlation: education, science and practice.

Think of a scenario in which theory, research, and practice interact to create good patient outcomes.

Write a minimum of 750- to 1000-word narrative explanation:

  • Describe the chosen theory, research, and practice guideline or standard. Provide citations for theory and practice guidelines.
  • Explain the relationship between the three (theory, research and practice) and discuss the role each plays in quality patient care in the scenario.
  • Explain any gaps, such as a lack of research, no practice standard, or no useable theory.
  • Determine the best course of action for making decisions in the absence of one aspect.

A minimum of two peer reviewed references is required.

Application: Planned Change in a Department or Unit

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Question Description
Assignment: Application: Planned Change
in a Department or Unit

Health care organizations are continuously immersed in change from the emergence of new policies, to promote quality care and improve patient safety to keeping pace with the rapid growth in knowledge and best practices. Establishing a solid framework for planning and implementing change is a wise move, as it provides a foundation for the extensive coordination that will be needed to successfully facilitate the change.

For this Assignment, you propose a change at the department or unit level and develop a plan for guiding the change effort.

To prepare:

  • Review Chapter 8 in the course text. Focus on Kurt Lewin’s change theory, and contrast it with other classic change models and strategies.
  • Reflect on problems, inefficiencies, and critical issues within a specific department, unit, or area in your organization or one with which you are familiar. Select one issue as a focal point for this assignment, and consider a change that could be made to address the issue.
  • Think about how the change would align with the organization’s mission, vision, and values as well as relevant professional standards.
  • Using one of the change models or strategies discussed in Chapter 8, begin formulating a plan for implementing the change within the department/unit. Outline the steps that you and/or others should follow to facilitate the change effort. Align these steps to the change model or strategy you selected.
  • Determine who should be involved in initiating and managing the change. Consider the skills and characteristics that are necessary to facilitate this change effort.

To complete:

Write a 3- to 5-page paper (page count does not include title and reference page) that addresses the following:

  • Identify a problem, inefficiency, or issue within a specific department/unit.
  • Describe a specific, realistic change that could be made to address the issue.
  • Summarize how the change would align with the organization’s mission, vision, and values as well as relevant professional standards.
  • Identify a change model or strategy to guide your planning for implementing the change. Provide a rationale for your selection.
  • Outline the steps that you and/or others would follow to facilitate the change. Align these steps to your selected change model or strategy.
  • Explain who would be involved in initiating and managing this change. Describe the skills and characteristics that would be necessary to facilitate the change effort.

Reminder: The School of Nursing requires that all papers submitted include a title page, introduction, summary, and references. The Sample Paper provided at the Walden Writing Centerhttp://academicguides.waldenu.edu/writingcenter/templates provides an example of those required elements. All papers submitted must use this formatting.

Donna, a twenty-one-year-old nursing student, comes to her nurse practitioner in December with a five-week history of itchy eyes and nasal congestion with watery nasal discharge.

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Question Description

Donna, a twenty-one-year-old nursing student, comes to her nurse practitioner in December with a five-week history of itchy eyes and nasal congestion with watery nasal discharge. She also complains of a “tickling” cough, especially at night, and she has had episodes of repetitive sneezing. She gets frequent “colds” every spring and fall.

Physical Examination

Vital Signs: Afebrile; respiratory rate, pulse, and blood pressure all normal

Skin: Flaking erythematous rash on the flexor surfaces of both arms

Head, Eyes, Ears, Nose, and Throat: Tender overmaxillary sinuses; sclera red and slightly swollen with frequent tearing; outer nares with red, irritated skin; internal nares with red, boggy, moist mucosa and one medium-sized polyp on each side; pharynx slightly erythematous, with clear postnasal drainage

Lungs: Clear to auscultation and percussion

Answer the questions about Donna and her condition and provide a pathophysiological response in the body. Examine and describe the pathophysiology associated with the possible disease.

  • What is the possible disease process according to the client’s history?
  • What assessment questions would be useful to ask about her medical and family history?
  • What evidence suggests that Donna does not have an acute severe infection?
  • If Donna has allergic rhinitis, what type of hypersensitivity reaction is involved?

Need a discussion in APA format.

Encourage to develop information literacy skills, effectively use APA format in creating a formal paper, develop clear and concise writing skills, and increase your knowledge and understanding of nursing informatics and healthcare information technology concepts.

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Question Description

Encourage to develop information literacy skills, effectively use APA format in creating a formal paper, develop clear and concise writing skills, and increase your knowledge and understanding of nursing informatics and healthcare information technology concepts.

TOPIC GUIDELINES

Apply informatics theory and content from the course modules, informed by current literature and course materials. Write for the topic below:

  • Telehealth/Telemedicine

Theoretical framework examples include, but are not limited to, the following:

  • Graves and Corcoran’s Model
  • Sciwirian’s Model
  • Turley’s Model
  • Data/Information/Knowledge/Wisdom (DIKW) Model
  • Sociotechnical Theory
  • Rogers’s Diffusion of Innovation Theory
  • Lewin’s Change Theory
  • Information Theory
  • General-System Theory
  • Chaos Theory

Note: The theoretical framework will serve as the underlying foundation for the paper. Here, you are to demonstrate how it may be applied to a specific nursing informatics issue.

Using that topic and the theoretical framework or model, write a paper for about 17 pages in narrative, not including the title and reference pages.

The paper should follow APA format and include the following sections:

  • Abstract
  • Introduction
  • Background
  • Body
  • Implications and conclusions with future directions
  • References (minimum 7 to 10)

select a program, quality improvement initiative, or other project from your place of employment. Assume you are presenting this program to the board for approval of funding.

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Question Description

In this assignment, you will select a program, quality improvement initiative, or other project from your place of employment. Assume you are presenting this program to the board for approval of funding. Write an executive summary (850-1,000 words) to present to the board, from which they will make their decision to fund your program or project. The summary should include:

  1. The purpose of the program or project.
  2. The target population or audience.
  3. The benefits of the program or project
  4. The cost or budget justification.
  5. The basis upon which the program or project will be evaluated.

Share your written proposal with your manager, supervisor or other colleague in a formal leadership position within a health care organization. Request their feedback using the following questions as prompts:

  1. Do you believe the proposal would be approved if formally proposed?
  2. What are some strengths and weaknesses of the proposal?

Submit the written proposal along with the “Executive Summary Feedback Form.”

Prepare this assignment according to the APA guidelines found in the APA Style Guide, located in the Student Success Center. An abstract is not required.

This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.