PRAC 6531 Episodic SOAP Note for Meditrek Patient 85

History of Present Illness Mnemonics

 

PQRST

P—palliative or provocative factors

Q—quality of pain

R—region affected

S—severity of pain

T—timing

 

LOCATES

L—location

O—onset

C—character

A—associated signs and symptoms

T—timing

E—exacerbating/relieving factors

S—severity

 

OLD CHARTS

O—onset

L—location

D—duration

CH—character

A—alleviating/aggravating

R—radiation

T—temporal pattern

S—symptoms associated

 

 

COLDERAS

C—character

O—onset

L—location

D—duration

E—exacerbating factors

R—relieving factors

A—associated signs and symptoms

S—severity

 

LIQORAAA

L—location

I—intensity

Q—quality

O—onset

R—radiation

A—associated signs and symptoms

A—alleviating factors

A—aggravating factors

QFLORIDAA

Q—quality

F—frequency

L—location

O—onset

R—radiation

I—intensity

D—duration

A—alleviating/aggravating

A—associated signs and symptom

Past Medical History

Use the past medical history (PMH) section to document the patient’s past and current health. Document when each condition was diagnosed, and indicate its present status, such as stable, uncontrolled, or resolved. You may subdivide information in the PMH into past medical history, past surgical history or other hospitalizations, medications, drug allergies, and health maintenance and immunizations. Using subheadings within the PMH, as shown in Table 2-3, makes it easier to locate information and identify the change from one topic to another. PRAC 6531 Episodic SOAP Note for Meditrek Patient 85

 

Table 2-3 Subheadings Used for Past Medical History

• Past Medical History
• Medical
• Surgical/hospitalizations
• Medications
• Allergies
• Health maintenance/immunizations

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if the patient has multiple medical problems, it may be helpful to document them as an enumerated list rather than in paragraph format. If the patient has had any surgery or hospitalizations for major trauma or other reasons, be sure to include the type of operation and date of the surgery; if known, you can include the name of the doctor who performed the surgery.

You should document a medication list as part of the PMH. This includes both prescription medications and over-the-counter products, such as herbal supplements, vitamins, minerals, and dietary supplements. PRAC 6531 Episodic SOAP Note for Meditrek Patient 85

Be sure to include the name of the medication, the dose, how frequently it is taken, and ideally, why the patient takes the medication. Review the list of medications with the patient at every visit to ensure accuracy.

It is extremely important to document any drug allergies the patient has. You may document food allergies in this section also.

You should document the specific reaction the patient experiences when the food or drug is ingested. In most settings, there will be a specific way to indicate a drug allergy, such as a special sticker affixed to the front of the patient’s chart, so that it is not overlooked.

In an electronic medical record (EMR), the text may be a different color or there may be a special tab or menu bar to highlight any allergies.

It is critically important to inquire specifically about and document an allergy to latex. A patient with a latex allergy will need special equipment.

You should document environmental allergies, such as an allergy to cats that results in allergic rhinitis, in the PMH.

If the patient is treated regularly for allergy-related conditions, document these conditions under the heading of Medical Conditions rather than Allergies.

The health maintenance and immunization section of the PMH will vary according to the patient’s age and gender.

Chapters 5, 6, and 7 discuss documentation of health maintenance activities and immunizations in the pediatric, adult, and older adult patient, respectively.

Family History

Typically, you should document the medical history of first-degree relatives, that is, the family history (FH) for parents, grandparents, siblings, and children.

Remember that a spouse’s medical history is not considered part of the patient’s FH, although it may be applicable in situations in which a couple presents because of infertility or genetic counseling.

Document the age and status (living, deceased, health status) of the first-degree relatives. If those relatives are deceased, include the age at time of death and cause of death.

If the relatives are still living, document their current age and medical conditions, paying particular attention to those conditions that have a familial tendency such as cardiovascular disease, diabetes, and certain cancers, osteoporosis, and sleep apnea.

Also determine whether any first-degree relatives have or had the condition with which the patient is presenting. In addition to medical conditions, inquire about any substance abuse, addictions, depression, or other mental health conditions of family members.

Social History

One of the main goals of documenting the social history (SH) of the patient is to identify factors outside of past or current medical conditions that may influence the patient’s overall health or behaviors that create risk factors for specific conditions.

These risk factors include use of tobacco, alcohol, and drugs. If these risk factors are present, document quantity of use and how long the use has occurred. Smoking history should include number of packs per day and the number of years the patient has smoked. PRAC 6531 Episodic SOAP Note for Meditrek Patient 85

If the patient formerly smoked or used smokeless tobacco, you still should document the details of the tobacco use with the addition of how long it has been since the patient quit. Avoid ambiguous terms such as social drinker that do not assist you or other readers in determining whether there is a risk factor associated with substance use.

Typically, the use of illegal substances is documented as drug use, but also you should determine whether the patient is taking substances prescribed for someone else or misusing prescription medication. If a risk factor is identified, be sure to include it in the problem list and assessment and plan.

Age-specific SH is discussed in other chapters. Information about the patient’s sexual orientation, gender identification, marital status, and number of children is included. Documentation of the patient’s past and current employment may help identify potential occupational hazards.

Include any military service and where stationed (stateside or overseas) as well as any possible exposures. If the patient has lived or traveled abroad, document locations and potential exposures, if any.

It is important to document the patient’s educational level and ability to read and write. If the patient speaks more than one language, you should document which language the patient prefers. PRAC 6531 Episodic SOAP Note for Meditrek Patient 85

Religion and religious and cultural beliefs may have an impact on a patient’s overall health. It can be difficult to determine the difference between a religious belief and a cultural belief, although typically it is not necessary to do so.

Specific documentation of the religious and cultural history includes beliefs related to health and illness, family, symbols, nutrition, special events, spirituality, and taboos. Table 2-4 shows questions that you can ask as part of the religious and cultural history.

 

Table 2-4Questions to Ask for Cultural and Religious History

 

Communication

• Is a translator needed?
• What is your primary oral language?
• What is your primary written language?

Beliefs Affecting Health and Illness

• What do you think caused your illness or condition?
• How does it affect your life?
• Have you seen anyone else about this problem?
• If yes, who?
• Have you used any home remedies for your problem?
• If yes, what?
• Are you willing to take prescription medications?
• Are you willing to use alternative therapies, such as herbal medicine?

Family

• Definition of family
• Roles within family
• Who has authority for decision-making related to your health care?

Symbols

• Special clothing
• Ritualistic and religious articles

 

Nutrition

• Specific food rituals
• Specific food avoidances
• Major foods
• Preparation practices

Special Events

• Prenatal care
• Death and burial rituals
• Beliefs of afterlife
• Willing to accept blood transfusions?
• Willing to accept organ transplantation?
• Organ, blood, or tissue donor?

Spirituality

• Dominant religion
• Active participant?
• Prayer and meditation
• Special activities
• Relationship between spiritual beliefs and health practices

Taboos

• Describe any taboos that would affect health care

 

Document nutritional information in terms of type of diet the patient follows, caffeine intake, and food allergies or avoidances. If there are questions or concerns about a patient’s diet, it may be helpful to record a “typical day” or “last 24 hours” of food intake.

Sedentary lifestyle is a risk factor for certain diseases, so document whether the patient exercises. If the patient exercises, include the type, frequency, and duration of exercise.

One basic consideration of a patient’s ability to access health care is whether the patient has health-care insurance or some other form of payment, such as Social Security or workers’ compensation.

Although financial records generally should be kept separate from the medical records, you should document whether the patient is insured or uninsured. If uninsured, information about income or ability to self-pay becomes essential. PRAC 6531 Episodic SOAP Note for Meditrek Patient 85

The provision or lack of insurance will guide many health-care choices, especially related to prescribing medications. Using generic instead of brand-name medications will result in cost savings for the patient and is often medically neutral, meaning the patient should get the same benefit from generic as from brand-name medications.

MEDICOLEGAL ALERT!

Documenting that you have counseled the patient on the risks of negative health habits and the management of chronic disease is an important part of the management of medicolegal risk.

Providers have been sued for not providing patient education and counseling. One such case involved a 33-year-old woman who was obese and hypertensive and smoked. She had frequent visits to the clinic for various complaints.

Routine screening tests revealed marked hypercholesterolemia and an abnormal ratio of high-density lipoprotein (HDL) to low-density lipoprotein (LDL). The health-care provider never counseled the patient regarding her risk for coronary artery disease.

Several years later, the patient presented to an emergency room with crushing chest pain that radiated to her arms and neck. The diagnosis of myocardial infarction was confirmed, but by the time the diagnosis was made, the window of opportunity for thrombolytic therapy had closed.

The patient sued the clinic and the health-care provider for malpractice. The health-care provider was found negligent for not educating and counseling the patient about her risk factors for developing heart disease.

Review of Systems (SUBJECTIVE)

The review of systems (ROS) is an inventory of specific body systems designed to document any symptoms the patient may be experiencing or has experienced.

Typically, you should document both positive symptoms (those the patient has experienced) and negative symptoms (those the patient denies having experienced).

A positive response from a patient about any symptom should prompt you to explore all elements of that symptom just as you would for the HPI (location, quality, severity, duration, timing, context, modifying factors, and associated signs and symptoms).

Rather than asking whether the patient has ever experienced any of the symptoms listed, it is appropriate to limit the review to a specific time frame. That time frame might change depending on the patient’s CC and HPI; if you are seeing a patient for the first time, it is usually sufficient to ask about the past year.

If the patient has been seen before, ask about the time frame since the previous visit.

Consistent with the 1995 and 1997 CMS guidelines, 14 systems are identified, and specific symptoms that should be explored in each system are included here. How many symptoms are explored within each system is up to you as indicated by the patient’s presenting complaint.

• Constitutional: these symptoms do not fit specifically with one system but often affect the general well-being or overall status of a patient. Specific symptoms include weight loss, weight gain, fatigue, weakness, fever, chills, and night sweats.
• Eyes: change in vision, date of last visual examination, glasses or contact lenses, history of eye surgery, eye pain, photophobia, diplopia, spots or floaters, discharge, excessive tearing, itching, cataracts, or glaucoma.
• Ears, nose, and mouth/throat (ENT):
• Ears: change in or loss of hearing, date of last auditory evaluation, hearing aids, history of ear surgery, ear pain, tinnitus, drainage from the ear, history of ear infections.
• Nose: changes in or loss of sense of smell, epistaxis, obstruction, polyps, rhinorrhea, itching, sneezing, sinus problems.
• Mouth/throat: date of last dental examination, ulcerations or other lesions of tongue or mucosa, bleeding gums, gingivitis, dentures, or any dental appliances.
• Cardiovascular (CV): chest pain, orthopnea, murmurs, palpitations, arrhythmias, dyspnea on exertion, paroxysmal nocturnal dyspnea, peripheral edema, claudication, date of last electrocardiogram or other cardiovascular studies.
• Respiratory: dyspnea, cough, amount and color of sputum, hemoptysis, history of pneumonia, date of last chest radiograph, date and result of last tuberculosis testing.
• Gastrointestinal (GI): abdominal pain; dysphagia; heartburn; nausea; vomiting; usual bowel habits and any change in bowel habits; use of aids such as fiber, laxatives, or stool softeners; melena; hematochezia; hematemesis; hemorrhoids; jaundice.
• Genitourinary (GU): frequency, urgency, dysuria, hematuria, polyuria, incontinence, sexual orientation, number of partners, history of sexually transmitted infections, infertility.

1. Males: hesitancy, change in urine stream, nocturia, penile discharge, erectile dysfunction, date of last testicular examination, date of last prostate examination, date and result of last prostate-specific antigen (PSA) test.
2. Females: GU symptoms as described previously and gynecological symptoms; age at menarche; gravida, para, abortions; frequency, duration, and flow of menstrual periods; date of last menstrual period; dysmenorrhea; type of contraception used; ability to achieve orgasm; dyspareunia; vaginal dryness, menopause; breast lesions, date and type of last breast imaging; date and result of last Papanicolaou smear, date of last pelvic examination. PRAC 6531 Episodic SOAP Note for Meditrek Patient 85

• Musculoskeletal (MSK): arthralgias, arthritis, gout, joint swelling, trauma, limitations in range of motion (ROM), back pain. (Note that numbness, tingling, and weakness are typically not included in musculoskeletal but in neurological system.)
• Integumentary: rashes, pruritus, bruising, dryness, skin cancer or other lesions.
• Neurological: syncope, seizures, numbness, tingling, weakness, gait disturbances, coordination problems, altered sensation, alteration in memory, difficulty concentrating, headaches, head trauma, or brain injury. (Headache, head trauma, or brain injury may also be listed under head, as part of Head, Eyes, Ears, Nose, Mouth/Throat, or HEENT.)
• Psychiatric: emotional disturbances, sleep disturbances, substance abuse disorders, hallucinations, illusions, delusions, affective or personality disorders, nervousness or irritability, suicidal ideation or past suicide attempts.
• Endocrine: polyuria, polydipsia, polyphagia, temperature intolerance, hormone therapy, changes in hair or skin texture.
• Hematologic/lymphatic: easy bruising, bleeding tendency, anemia, blood transfusions, thromboembolic disorders, lymphadenopathy.
• Allergic/immunologic: allergic rhinitis, asthma, atopy, food allergies, immunotherapy, frequent or chronic infections, HIV status; if HIV positive, date and result of last CD4 count.

You may use standard forms or templates for gathering much of the history information, and this is certainly an acceptable, time-saving practice.

However, you have an obligation to review and verify the information that the patient provides. Staff members may use the forms to enter information into an EMR. The original paper forms should be scanned into the EMR.

 Physical Examination (OBJECTIVE)

The rationale for physical examination rests on a basic assumption that there is such a thing as normality of bodily structure and function corresponding to a state of health and that departures from this norm consistently result from or correlate with specific abnormal states or disease.

It is helpful to think about a “range of normal” when it comes to physical examination findings, rather than a single “normal” for every part of the examination.

The physical examination may confirm or refute a diagnosis suspected from the history, and by adding this information to the database, you will be able to construct a more accurate problem list.

Like the history, the physical examination is structured to record both positive and negative findings in detail.

Generally, the examination will proceed in a head-to-toe fashion. In some instances, it may be necessary to deviate from this order, such as performing an invasive component at the end of the examination or examining an area of pain last.

Regardless of the order in which the examination is performed, documentation of the physical examination should follow the order that follows and in Table 2-5. PRAC 6531 Episodic SOAP Note for Meditrek Patient 85

Consult other textbooks for instruction on how to perform the physical examination and for a discussion on the importance of any findings; here the emphasis is on the documentation of a comprehensive physical examination.

 

General assessment (OBJECTIVE)

• Vital signs: temperature, pulse, respiration, blood pressure, height, weight, body mass index (BMI)
• Skin
• HEENT
• Neck
• Respiratory
• Cardiovascular
• Abdomen
• Genitourinary or gynecological
• Musculoskeletal
• Neurological

 

General: age, race, gender, general appearance. Documentation of general appearance could include alertness, orientation, mood, affect, gait, how a patient sits on the examination table or chair, grooming, and the patient’s reliability to provide an adequate history.

Document whether the patient is in any distress or whether the patient appears markedly older or younger than the stated age.

OBJECTIVE DATA

• Vital signs: temperature, blood pressure, pulse, respiratory rate, height, weight, and body mass index (BMI).
• Skin: presence and description of any lesions, scars, tattoos, moles, texture, turgor, temperature; hair texture, distribution pattern; nail texture, nail base angle, ridging, pitting.
• HEENT:
• Head (including face): size and contour of head, symmetry of facial features, characteristic facies, tenderness, or bruits of temporal arteries.
• Eyes: conjunctivae; sclera; lids; pupil size, shape, and reactivity; extraocular movement (EOM); nystagmus; visual acuity. Ophthalmoscopic findings of cornea, lens, retina, red reflex, optic disc color and size, cupping, spontaneous venous pulsations, hemorrhages, exudates, nicking, arteriovenous crossings.
• Ears: integrity, color, landmarks, and mobility of the tympanic membranes; tenderness, discharge, external canal, tenderness of auricles, nodules.
• Nose: symmetry, alignment of septum, nasal patency, appearance of turbinates, presence of discharge, polyps, palpation of frontal and maxillary sinuses.
• Mouth/throat: lips, teeth, gums, tongue, buccal mucosa, tonsillar size, exudate, erythema.
• Neck: ROM, cervical and clavicular lymph nodes, thyroid examination, position, and mobility of the trachea.
• Respiratory: effort of breathing, breath sounds, adventitious sounds, chest wall expansion, symmetry of breathing, diaphragmatic excursion.
• Cardiovascular: heart sounds, murmurs or extra sounds, rhythm, point of maximal impulse, peripheral edema, central and peripheral pulses, varicosities, venous hums, bruits.
• Breast: symmetry, inspection for dimpling of skin, nipple discharge, palpation for tenderness, cyst or masses, axillary nodes, gynecomastia in males.
• Abdomen: shape (flat, scaphoid, distended, obese), bowel sounds, masses, organomegaly, tenderness, inguinal nodes.
• Male genitalia or gynecological (breast examination sometimes documented here).
• Male genitalia: hair distribution, nits, testes, scrotum, penis, circumcised or uncircumcised, varicocele, masses, tenderness.
• Gynecological: External inspection of the perineum for lesions, nits, hair distribution, areas of swelling or tenderness, labia and labial folds, Skenes and Bartholin glands, vaginal introitus; noting any discharge or cystocele if present. Internal—inspect vaginal walls and cervix for color, discharge, lesions, bleeding, atrophy; inspect cervical os for size and shape; bimanual examination for size, shape, consistency and mobility of the cervix; cervical motion tenderness, uterine or ovarian enlargement, masses, tenderness, adnexal masses or tenderness.
• Rectal: hemorrhoids, fissures, sphincter tone, masses, rectocele; if stool is present, color and consistency of stool, test stool for occult blood; prostate examination for males, noting size, uniformity, nodules, tenderness.
• Musculoskeletal: symmetry of upper and lower extremities, ROM of joints, joint swelling, redness or tenderness, amputations; inspection and palpation of spine for kyphosis, lordosis, scoliosis, musculature, range of motion, muscles for spasm, or tenderness. PRAC 6531 Episodic SOAP Note for Meditrek Patient 85
• Neurological:
• Mental status: level of alertness; orientation to person, time, place, and circumstances; psychiatric mental status or mini–mental state examinations if indicated.
• Cranial nerves: see Table 2-6 for details of the 12 cranial nerves and their functions.
• Motor: strength testing of upper and lower extremity muscle groups proximally and distally graded on a scale of 0 to 5 as shown in Table 2-7.
• Cerebellum: Romberg test, heel to shin, finger to nose, heel-and-toe walking, rapid alternating movements.
• Sensory: sharp/dull discrimination, temperature, stereognosis, graphesthesia, vibration, proprioception.
• Reflexes: brachioradialis, biceps, triceps, quadriceps (knee), and ankle graded on a scale of 0 to 4+ as shown in Table 2-8.

Based on your reading, complete the application exercises that follow.

Cranial Nerve Number, Name, and Major Function

I Olfactory – Smell

II Optic – Visual acuity, visual fields, fundi; afferent limb of pupillary response

III, IV, VI – Oculomotor, trochlear, abducens – Efferent limb of pupillary response, eye movements

V – Trigeminal – Afferent corneal reflex, facial sensation, masseter and temporalis muscle testing by biting down

VI- Facial- Raise eyebrows, close eyes tight, show teeth, smile or whistle, efferent corneal reflex

VIII – Acoustic – Hearing

IX, X – Glossopharyngeal and vagus – Palate moves in midline, gag reflex, speech

XI – Spinal accessory- Shoulder shrug, push head against resistance

XII – Hypoglossal – Stick out tongue

Table 2-7 Muscle Strength Grading

Muscle Grading and Meaning

0   – No motion or muscular contraction detected

1 – Barely detectable motion

2 – Active motion with gravity eliminated

3 – Active motion against gravity

4 – Active motion against some resistance

5 – Active motion against full resistance

Grading Reflex and Meaning

0       Absent

1+     Decreased or less than normal

2+     Normal or average

3+     Brisker than usual

4+     Hyperactive with clonus

Laboratory and Diagnostic Studies

Following documentation of the H&P, document the results of any studies, such as laboratory tests, radiographs, or other imaging studies.

All results should be specifically recorded. For instance, rather than documenting, “the complete blood count (CBC) is normal,” document the value for each part of the CBC. This is done for several reasons.

First, it presents the actual values and allows readers of the H&P to formulate their own conclusions regarding the meaning of the values. Second, it documents the baseline values that the patient has as a reference point.

Third, it saves time for other readers to have the values listed rather than having to look them up.

Problem List, Assessment, and Differential Diagnosis

Once you have documented all the elements of the H&P and results of diagnostic studies, you can evaluate all the information to identify the patient’s problems. Use a numbered list that includes the date of onset and whether a particular problem is active or inactive. List the most severe problems first.

After the initial list is generated, new problems are listed chronologically.

Make an assessment of each current problem. This entails a brief evaluation of the problem with differential diagnosis.

This is a very important component of the comprehensive H&P because it demonstrates your judgment and documents the medical decision-making that you considered regarding each problem.

Plan of Care

Document any additional studies or workup needed, referrals or consultations needed, pharmacological management, nonpharmacological or other management, patient education, and disposition such as “return to clinic” or “admit to the hospital.”

There are different ways that you can document the assessment and plan. Sometimes you will see assessment and plan documented as numbered or bulleted lists under separate headings, or you may see them together.

Example 2.1 demonstrates the difference in these approaches. Either is acceptable and which is used depends largely on health-care provider preference and whether documentation is paper-based or EMR-based.

EXAMPLE 2.1

Assessment:

1. Cough: nonproductive and no signs or symptoms of infectious process. Recently started an angiotensin-converting enzyme (ACE) inhibitor, so may be side effect of medication.
2. Diabetes, not well controlled: review of home glucose monitoring logs shows fasting range of 150 to 180.
3. New onset left leg swelling: no trauma, no erythema. Pulses are present. Concern for deep vein thrombosis (DVT). PRAC 6531 Episodic SOAP Note for Meditrek Patient 85

Plan:

1. Stop ACE inhibitor. Will switch to losartan 50 mg once daily.
2. Check HgbA1C; continue metformin, add glipizide 5 mg twice daily. Continue home glucose monitoring.
3. Left leg Doppler flow study.

Return to clinic in 2 weeks.

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Assessment/Plan:

1. Cough: nonproductive and no signs or symptoms of infectious process. Recently started an ACE inhibitor, so may be side effect of medication. Stop ACE inhibitor. Will switch to losartan 50 mg once daily.
2. Diabetes, not well controlled: review of home glucose monitoring logs shows fasting range of 150 to 180. Check HgbA1C; continue metformin, add glipizide 5 mg twice daily. Continue home glucose monitoring.
3. New onset left leg swelling: no trauma, no erythema. Pulses are present. Concern for DVT; left leg Doppler flow study.

Return to clinic in 2 weeks.

Sample Comprehensive History and Physical Examination

A sample comprehensive H&P for Mr. William Jensen is shown in Figure 2-2. Mr. Jensen is a new patient to the practice of Dr. Vernon Scott, and you will follow his medical course through the documentation of his encounters with a surgeon, his admission to the hospital, surgery, hospital course, and discharge.

In addition to documentation related to Mr. Jensen, you will have the opportunity to evaluate other documentation.

Summary

The comprehensive history and physical examination (H&P) is one of the most important documents in the patient’s entire medical record.

The H&P will vary somewhat in content at different ages and stages of life and among different medical disciplines as discussed in other chapters; however, the structure of the H&P is typically the same.

Typically, you will complete the comprehensive H&P at an initial patient visit in the ambulatory setting, and documentation of subsequent visits will not be as detailed.

The goal of the H&P is to elicit detailed information about the patient’s medical history to identify risk factors, guide decisions for health maintenance, and to identify and treat conditions that will impact the patient’s health and quality of life.

Completing the worksheets that follow will help reinforce the material presented in this chapter.

And be sure to review Appendix A, the Document Library, for full case examples of patient documentation. PRAC 6531 Episodic SOAP Note for Meditrek Patient 85

Discussion: Career Goals: Strengths and Challenges Related to Nursing Practice Competencies

NRNP WK1 Discussion

Discussion: Career Goals: Strengths and Challenges Related to Nursing Practice Competencies

An advanced practice nurse collaborates and communicates with patients, families, doctors, nurses, and specialists to ensure patients receive the care they need.

As they diagnose, treat, manage, and educate patients, they are responsible for ensuring patient safety and maintaining ethical behavior.

Competencies have been developed to help the advanced practice nurse to understand the practice knowledge, skills, and attitudes they need to be successful.

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Photo Credit: michaeljung / Adobe Stock

For this Discussion, you will examine advanced nursing practice competencies and reflect on your strengths and challenges related to the competencies. Discussion: Career Goals: Strengths and Challenges Related to Nursing Practice Competencies

In light of your reflection, you will consider how this course may help you attain your career goals or objectives.

To prepare:

• Review the Learning Resources for this week, specifically the advanced nursing practice competencies. As you review the competencies, reflect on your own strengths and challenges when working with adults across the lifespan.

By Day 3

Post a summary of your expectations of this course. Also, include a brief explanation of your strengths and challenges as they relate to nursing practice competencies when working with adults.

Describe any career goals or objectives this course may help you accomplish in the Family Nurse Practitioner (FNP) or Adult-Gerontology Primary Care Nurse Practitioner (AGPCNP) role and explain why.

Use your research to support your explanations by providing credible and scholarly sources.

Read a selection of your colleagues’ responses.

By Day 6

Respond to at least two of your colleagues on two different days by offering a suggestion or resources to help your colleagues in addressing their personal strengths or challenges, or their career goals.

Use your research to support your suggestions. Provide at least 3 credible and current scholarly sources.

Note: For this Discussion, you are required to complete your initial post before you will be able to view and respond to your colleagues’ postings. Discussion: Career Goals: Strengths and Challenges Related to Nursing Practice Competencies

Begin by clicking on the Post to Discussion Question link and then select Create Thread to complete your initial post.

Remember, once you click Submit, you cannot delete or edit your own posts, and you cannot post anonymously. Please check your post carefully before clicking on Submit!

Submission and Grading Information

Grading Criteria

To access your rubric:

Week 1 Discussion Rubric

Post by Day 3 and Respond by Day 6

To Participate in this Discussion:

Week 1 Discussion

Assignment

Strengths and Challenges Related to Nursing Practice Competencies

Student’s Name

Institution of Affiliation

Professor’s Name

Course ID

Date of Submission

Strengths and Challenges Related to Nursing Practice Competencies

Nursing competencies refer to the ability of nurses to take appropriate action in their nursing practices through the utilization of knowledge, skills, beliefs, and past experiences.

This allows them to effectively perform their role and collaborate with other parties in an organization. Advanced practice nurses need to have a comprehensive understanding of the strengths and challenges to perform their roles successfully.

Through the course, students learn how Adult-Gerontology Primary Care Nurse Practitioner (AGPCNP) perform their duties in making decisions and taking care of adult populations.

The course should also help students diagnose and manage primary healthcare patients and identify problems among the adults and elderly population.

Through the course, we will acquire more knowledge regarding physical and behavioral diseases in the primary diagnosis process (Farrell, Payne, & Heye, 2015). Therefore students can plan, implement, and evaluate evidence-based approaches that promote health in primary care patients.

I also expect to acquire the skills and confidence required in a clinical set up by the end of the course. Hence I can comprehend how to plan, evaluate and execute therapeutic systems for adult patients with chronic or acute illnesses. Discussion: Career Goals: Strengths and Challenges Related to Nursing Practice Competencies

Particular competencies are essential in (AGPCNP). An AGPCNP is a nurse who specializes in promoting and sustaining health, particularly among culturally; diverse and high-risk populations.

These nurses can examine and manage health conditions across different age populations, from adolescents to older adults suffering from acute and several chronic illnesses.

As an AGPCNP student, competencies to acquire include assessing and intervening in situations, effective communications, critical thinking, and patient caring and relations helps them perform their duties effectively (Hwang 2015).

The required to fulfill competencies include monitoring, therapeutic approaches, reporting, and computing skills. Their extensive research skills significantly contribute to critical thinking.

Lastly, having the proper ethical values and patient advocacy ensures that nurses relate well with their patients.

There are several strengths attributed to the nursing competencies of AGPCNP. The first is relationship management, where through their communication and relationship competencies, they can deliver disturbing news that will not affect the health issues of a patient (Fukada 2018).

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This is incredibly impactful with the elderly population. Other skills that strengthen their competencies include teamwork and collaboration, knowledge of evidence-based practices, health, quality improvement, and safety (Want, Goodman, and Selway, 2021).

The practitioners’ challenges are increased workload since more patients are being diagnosed with multiple chronic conditions among adolescents, adults, and older adults.

An Adult-Gerontology  Primary Care Nurse Practitioner (AGPCNP) is intensely committed to managing their patients’ health and community.

My career goal is striving to prevent illnesses by educating communities and patients on healthy lifestyle habits. I will also provide education and sufficient knowledge to the patients on healthcare choices to avoid diabetes and, obesity among others.

I firmly find passion in providing primary care to patients because they also get to self-manage themselves regarding their health.

I also strongly advocate for collaboration among community members to promote a healthier society. The course will help me acquire the skills necessary to examine patients, diagnose, and treat, among others necessary for promoting a patient’s health.

I will also develop skills to train patients on how to self-manage themselves, develop healthy lifestyles to enhance health and prevent illnesses.

These skills will help me perform my duties effectively and collaborate with nurses, doctors, patients, and other practitioners.

Refereces

Farrell, K., Payne, C., & Heye, M. (2015). Integrating interprofessional collaboration skills into the advanced practice registered nurse socialization process. Journal of Professional Nursing, 31(1), 5-10.

Fukada M. (2018). Nursing Competency: Definition, Structure, and Development. Yonago Acta Medica, 61(1), 1–7. https://doi.org/10.33160/yam.2018.03.001

wang, J. I. (2015). What are hospital nurses’ strengths and weaknesses in patient safety competence? Findings from three Korean hospitals. International Journal for Quality in Health Care, 27(3), 232-238

Want, D., Goodman, P., and Selway, J., 2021. Primary Care Nurse Practitioner Clinical Procedural Skills. The Journal for Nurse Practitioners. Discussion: Career Goals: Strengths and Challenges Related to Nursing Practice Competencies

Assignment 1: Lab Assignment: Assessing the Genitalia and Rectum

This week’s focus is on the Assessing the Genitalia and Rectum.

For this assignment, you will analyze an Episodic note case study that describes abnormal findings in patients seen in a clinical setting.

You will consider what history should be collected from the patients, as well as which physical exams and diagnostic tests should be conducted. You will also formulate a differential diagnosis with several possible conditions.

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Assignment 1

Assignment 1: Lab Assignment: Assessing the Genitalia and Rectum

Review the following Episodic note case study:

 Subjective:

• CC: dysuria and urinary frequency
• HPI: RG is a 30-year-old female with increase urinary frequency and dysuria that began 3 days ago. Pain is intermittent and described a burning only in urination, but c/o flank pain since last night.
• Reports intermittent chills and fever. Used Tylenol for pain with no relief. She rates her pain 6/10 on urination. Reports a similar episode 3 years ago.
• PMH: UTI 3 years ago
• PSHx: Hysterectomy at 25 years
• Medication: Tylenol 1000 mg PO every 6 hours for pain
• FHx: Mother breast cancer (alive) Father hypertension (alive)
• Social: Single, no tobacco, works as a bartender, positive for ETOH
• Allergies: PCN and Sulfa
• LMP: N/A

Review of Symptoms:

• General: Denies weight change, positive for sleeping difficulty because e the flank pain. Feels warm.
• Abdominal: Denies nausea and vomiting. No appetite. Assignment 1: Lab Assignment: Assessing the Genitalia and Rectum

Objective:

• VS: Temp 100.9; BP: 136/80; RR 18; HT 6’.0”; WT 135lbs
• Abdominal: Bowel sounds present x 4. Palpation pain in both lower quadrants. CVA tenderness
• Diagnostics: Urine specimen collected, STD testing

Assessment:

• UTI
• STD
• PLAN:This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.
• • Consider what history would be necessary to collect from the patient in the case study.
  • Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis?
  • Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.
    

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The Lab Assignment (Please complete in a narrative format so you can explain your thoughts fully. Do not add information in an episodic note format)

Using evidence-based resources from your search, answer the following questions and support your answers using current evidence from the literature.

• Analyze the subjective portion of the note. List additional information that should be included in the documentation.
• Analyze the objective portion of the note. List additional information that should be included in the documentation.
• Is the assessment supported by the subjective and objective information? Why or why not?
• Would diagnostics be appropriate for this case, and how would the results be used to make a diagnosis?

Would you reject/accept the current diagnosis? Why or why not? Identify three possible conditions that may be considered as a differential diagnosis for this patient.

Explain your reasoning using at least three different references from current evidence-based literature.

Assignment 1: Lab Assignment: Assessing the Genitalia and Rectum

Photo Credit: Getty Images

Patients are frequently uncomfortable discussing with healthcare professional’s issues that involve the genitalia and rectum; however, gathering an adequate history and properly conducting a physical exam are vital.

Examining case studies of genital and rectal abnormalities can help prepare advanced practice nurses to accurately assess patients with problems in these areas. Assignment 1: Lab Assignment: Assessing the Genitalia and Rectum

In this Lab Assignment, you will analyze an Episodic note case study that describes abnormal findings in patients seen in a clinical setting.

You will consider what history should be collected from the patients, as well as which physical exams and diagnostic tests should be conducted. You will also formulate a differential diagnosis with several possible conditions.

To Prepare

• Review the Episodic note case study your instructor provides you for this week’s Assignment. Please see the “Course Announcements” section of the classroom for your Episodic note case study.
• Based on the Episodic note case study:
  • Review this week’s Learning Resources, and consider the insights they provide about the case study. Refer to Chapter 3 of the Sullivan resource to guide you as you complete your Lab Assignment.
  • Search the Walden library or the Internet for evidence-based resources to support your answers to the questions provided.
  • Consider what history would be necessary to collect from the patient in the case study.
  • Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis?
  • Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.

The Lab Assignment

Using evidence-based resources from your search, answer the following questions and support your answers using current evidence from the literature.

• Analyze the subjective portion of the note. List additional information that should be included in the documentation.
• Analyze the objective portion of the note. List additional information that should be included in the documentation.
• Is the assessment supported by the subjective and objective information? Why or why not?
• Would diagnostics be appropriate for this case, and how would the results be used to make a diagnosis?
• Would you reject/accept the current diagnosis? Why or why not? Identify three possible conditions that may be considered as a differential diagnosis for this patient. Explain your reasoning using at least three different references from current evidence-based literature. Assignment 1: Lab Assignment: Assessing the Genitalia and Rectum

WK8 Discussion Response Episodic/Focused SOAP Note Back Pain

Response #1

Instructions: Just need a response to Gert Marais Post (feedback)

 

Gert Marais 

Back Pain “Initial Post”

COLLAPSE

Top of Form

Episodic/Focused SOAP Note Back Pain

 

Patient Information:

J.M, 42 y.o, Male, Caucasian

S.

CC (Lower Back Pain) “Something is wrong with my back”

HPI: 42 y.o male comes in today for with complaints of lower back pain for a month now. Patient says “he was doing landscaping and shoveling dirt when he felt a sharp shock of pain in his back and it caused him to drop to his knees.

The pain subsided some but his back became tight and caused both his hamstrings to cramp up if he tried to stretch his back, and sometimes a sharp shock feeling goes down his left hip to the back of his left leg and into his calf”.

Patient rates worst pain to be 8/10 in his lower back and 5/10 in his left leg. Patient states the pain never drops below 3/10 and intense pain last a few seconds to a few minutes.

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Patient says warm showers and rest seem to work the best and ibuprofen and Tylenol does not seem to help. Patient says he cannot tolerate holding weight and cannot seem to bend backwards without a sharp sock going down his lower back and left leg. WK8 Discussion Response Episodic/Focused SOAP Note Back Pain

Current Medications:

1.)    Ibuprofen 800 mg PO Q6hr PRN for pain.

2.)    Tylenol 600mg PO Q4 PRN for pain

Allergies:

Medication Allergy: Denies

•             Food Allergy: Denies
•             Environmental Allergy: Bee stings: Moderate swelling to limb. Denies respiratory distress.

Past Medical History: Denies medical history “I have always been a healthy guy, heck I hardly get sick. I did break my left arm in football when I was a freshman in high school”

Past Surgical History (PSH):

1.)    Appendectomy age 10.

Sexual/Reproductive History: “I am married and devoted to my wife. We have been married for 15 years and we are not worried about sexual diseases, and we do not have any sexual diseases”.

 Personal/Social History: Denies smoking “I have never smoked in my life”. Endorses seldom use of ETOH consumption “I probably drink maybe 5 beers in total a year”.

Denies illicit drug use “I have always had a good head on my shoulders, I never got involved with that stuff”. Patient states he does heavy weightlifting since high school and has not been able to do any cardo or lifting since his back injury”.

Patient states “I purposely gain or lose weight for lifting purposes, but recently I have been gaining a bit more weight and finding it harder to lose weight”. WK8 Discussion Response Episodic/Focused SOAP Note Back Pain

Patient states his diet is mostly fish, chicken, rice, and occasional red meats. Patient states married only once and have an 8 y.o son. Patient denies risky behavior, activities.

Patient states he lives in a “good neighborhood with plenty of fresh air”.

Immunization History: Patient states “I should be up to date on shots, I have my immunizations reviewed about twice a year with my checkups”

1.)    Denies ever receiving covid-19 vaccine

2.)    States “I just got my flu shot last month”

Fam Hx: illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for death of any deceased first degree relatives should be included.

Include parents, grandparents, siblings, and children. Include grandchildren if pertinent.

• 1  Father: Inguinal hernia age 35. Died of car accident age 42.
• 2   Mother: Died of breast cancer age 32.
• 3 Brother: “He is struggling with weight, but he is active and healthy otherwise” age 45.
• 4  Sister: “struggling with weight, but active and healthy with 2 kids”. Alive age 38.
• 5  Maternal grandfather: Died from plane crash age 52.
• 6   Maternal grandmother: Hypertension. Alive 78.
• 7   Paternal grandfather: Died from stroke age 75.
• 8   Paternal grandmother: “Alive and doing well for 81”
• 9   Son: Healthy age 8

ROS:

GENERAL:  Denies weight loss without trying.  Denies “feeling sick”. Denies fever, chills, weakness or fatigue. Patient states “I am pretty fit and healthy, I just have not been able to do anything since my back injury”.

Cardiovascular/Peripheral Vascular: Denies chest pain/discomfort.  Patient denies concerns about his cardiovascular “I have a healthy heart and I have no concerns with in not working properly”. Denies history of angina after workouts. Denies edema.

Respiratory: Denies shortness of breath/ distress. Patient states “My breathing is excellent and I don’t feel out of breath after doing mild to moderate physical activity”.  Patient states “Before my injury I use to run 3-5 miles a week at moderate speed and walk 3-5 miles as well for cardio”

Gastrointestinal: States last BM “I have daily soft formed stool”. Denies constipation, diarrhea.  Patient states “It is difficult for me to have to sit down and poop because it is painful to try and sit with my back hurting”.

Denies issues with urination/ voiding. Denies N/V. Denies heartburn or GERD. Patient states “I sometimes get hemorrhoids but they are pretty mild and tend to go away”. WK8 Discussion Response Episodic/Focused SOAP Note Back Pain

Neurological: Endorses sharp pain to his left hip which radiates down to the back of his leg and into his calf. Patient states pain is more intense and sharp when leaning backwards verses more aching and dull pain when leaning forward.

Denies tingling sensation. Patient denies paralysis of extremities.

Musculoskeletal: Patient states “I cannot walk normally and find myself to be off balance because of sudden sharp pains in my back causing me to crumble to my knees”.

Patient states he has to walk slowly with bracing his hips with his hands to try and relieve pain. Patient states he also will have hamstring cramps when trying to get out of bed or moving after resting for a while. Patient denies weakness to extremities.

Patient states “My lower back feels like it starts to tighten and then I feel a tremble followed by pain”. Patient denies budging of the skin, denies notice of masses or protrusions.

Psychiatric: Denies SI/HI/AVH. Rates anxiety moderate “I am worried that I won’t be able to do any physical activity and keep up with my stress relieving coping skills of working out”, rates depression low.

O.

Physical Exam:

Vital signs: BP 128/75 RA sitting. HR 78, RR 16, 99% O2, 36.6C Temp. 89.54Kg, 182.8 cm. 5/10 Pain lower back pain.

General: Patient presents as bright, calm, cooperative, and grimacing intermittently in response to pain in his lower back.  Patient appears healthy. Age appropriate for presentation.

Skin appropriate for ethnicity, no wounds/ sores/rashes/bruises noted. Skin warm, dry, and non-tenting.  Gait abnormal: patient leaning left and forward during gait with intermittent loss of balance in response to pain.

Patient sitting with requiring lower back support, patient shifting in chair. Patient able to stand without support. No weakness noted in extremities, but limited to fully engagement of muscles lower extremities due to pain.

Appropriate hygiene practices, well groomed. Patient is A&Ox4. Patient is engaging with assessment.

Physical exam:

Cardiovascular/Peripheral Vascular:

Chest symmetrical bilaterally, no visible abnormal finding. No edema or swelling noted in extremities. Capillary refill less than 3 seconds for hands and feet.

No abnormal finding with heart auscultation presenting with S1, S2. Femoral arteries palpated +2 expected findings. Popliteal arteries palpated +2 expected findings. Right and left tibial arteries palpated +2 bilaterally expected findings.

Respiratory: Breath sounds present in all areas, no adventitious sounds present.

Gastrointestinal: Abdomen symmetrical, flat contour, with no abnormal findings. Normoactive bowel sounds present in all four quadrants. None tender with light and deep palpitation.

Musculoskeletal: Spine curvature presents as normal with no kyphosis or lack of lower lumbar lordosis. No scoliosis present with patient bending forward.

Spinal pain present with palpation at L4 to S1. Paraspinus muscles presenting with palpation tenderness L3 to L4. Positive tripod sign with left leg being raised and patient eliciting straightened arm and bracing in a triangular position.

Positive Straight leg sign to left leg eliciting pain around 30 to 60 degrees and dorsiflex of foot elicits pain after 15 degree drop to leg. Femoral stretch test for L2 to L4 with mild elicit of pain.

Neurological: Motor strength L4 test: thighs equal in strength. L5 Motor strength test dorsiflex of feet presented with equal strength in both feet.

S1 motor strength test with planter flex of feet: strength equal bilaterally. Feet bilaterally raised when walking on heels, no foot drop noted. WK8 Discussion Response Episodic/Focused SOAP Note Back Pain

Both heels raised with no drop noted when walking on his toes. No noted differences in dermatomes to thighs when assessed with needle.

No noted differences in dermatomes for L5. No noted differences in dermatomes for S1. L4 elicits patellar tendon reflex to left and right leg.

Medial hamstring elicits reflex for right and left leg. Elicit of jerk to Achilles tendon present in both right and left leg.  Neurological exam resulted with no abnormal findings.

Skin: Skin appropriate for race, no wounds/ sores/rashes/bruises noted. Skin warm, dry, non-tenting.

Diagnostic results:

Recommendations for no abnormal findings in neurological exam is not to proceed with imaging at this time, but have the patient come back in 6-8 weeks if symptoms are not improving (Singh, 2020).

•   CBC to rule out infection: “Complete blood count is ordered along with or prior to the blood culture to determine whether the person has an increased number of white blood cells (or in some cases, a decreased number of white blood cells), indicating a potential infection
•    C-reactive protein (CRP) level: Helps indicate inflammatory marker in the body (Arthritis Foundation, 2020).
  

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A.

Differential Diagnoses

1.  Back sprain: Indicator with mode of injury (physical straining activity) and positive finding with paraspinus muscles presenting with tenderness. Location commonly “Low back, buttock, posterior. Quality of pain: aches/spasms. Aggravating symptoms: increased with activity” (Patel & Ogle, 2000).
2.   Acute disc herniation: Sharp pain radiating down affected side. “Positive straight leg raise test. Low back to lower leg pain. Sharp shooting or burning pain in leg. Increased pain with bending or sitting” (Patel & Ogle, 2000).
3.  Spondylolisthesis: Symptoms include “Muscle spasms in the hamstrings, back stiffness, difficulty walking or standing, pain with bending over” (Cleveland Clinic, 2020).
4.  Infection: “Pain in lumbar spine, sacrum. Pain is sharp and aches” (Patel & Ogle, 2000).
5.  Inflammatory arthritis: “all arthritis leads to inflammation, arthritis is categorized as inflammatory and noninflammatory (degenerative) based on its origin” (John Hopkins, 2021).  Spinal arthritis can cause “Radiculopathy – pinching of the peripheral nerves as they exit the spine (sciatica is one type of radiculopathy” (John Hopkins, 2021).

 References

Arthritis Foundation. (2020). Blood, Fluid and Tissue Tests for Arthritis. Blood, fluid and tissue tests for arthritis. Retrieved October 21, 2021, from https://www.arthritis.org/health-wellness/about-arthritis/understanding-arthritis/blood,-fluid-and-tissue-tests-for-arthritis.

Cleveland Clinic. (2020, August). Spondylolisthesis: What is it, causes, symptoms & treatment. Cleveland Clinic. Retrieved October 21, 2021, from https://my.clevelandclinic.org/health/diseases/10302-spondylolisthesis.

John Hopkins. (2021, January). Spinal arthritis (arthritis in the back or neck). Johns Hopkins Medicine. Retrieved October 21, 2021, from https://www.hopkinsmedicine.org/health/conditions-and-diseases/spinal-arthritis.

Patel, A., & Ogle, A. (2000, March 15). Diagnosis and management of acute low back pain. American Family Physician. Retrieved October 21, 2021, from https://www.aafp.org/afp/2000/0315/p1779.html.

Singh, B. (2020). Low back exam, approach to. Stanford Medicine 25. Retrieved October 21, 2021, from https://stanfordmedicine25.stanford.edu/the25/BackExam.html. WK8 Discussion Response Episodic/Focused SOAP Note Back Pain