PRAC 6541: Primary Care of Adolescents and Children

Write A Focused Soap Note

A mother brings her 14-year-old daughter to the clinic because of a persistent facial rash that has been present for 3 to 4 weeks. The child is restless at night and scratches in her sleep. She is otherwise healthy. Physical examination reveals a well-nourished, healthy-appearing girl with dry, red, scaly areas on the cheeks, chin, chest, and around the mouth, as well as on the extensor surfaces of her extremities. The areas on the cheeks have a plaque-like, weepy appearance with papules. The remainder of the child’s examination is normal. Atopic Dermatitis

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Focused SOAP Checklist

 

SUBJECTIVE:

• Chief Complaint: Did I state briefly in the patient’s own words
• History of present illness: Did I write a paragraph in the order of the 7 attributes & did I put the 7 attributes in a concise list in the chart (OLD CART-if you don’t know it, please look it up)
• Medications: did I list each medication and reason.
• Allergies: Did I include specific reactions to medications, foods, and insects, environmental?
• Past Medical History (PMH): Did I list all the patient Illnesses, hospitalizations? Did I Include childhood illnesses
• Past Surgical History (PSH): Did I list the dates, indications and types of operations?
• OB/GYN History: (if applicable) Obstetric history, menstrual history, methods of contraception and sexual function. PRAC 6541: Primary Care of Adolescents and Children
• Personal/Social History: Tobacco use, Alcohol use, Drug use, risky sexual behavior. Patient’s interests, ADL’s IADL’s if applicable. Exercise, eating habits. Pediatrics: school status, parental smoking hx, birth history, school/daycare etc
• Immunizations: Did I include Last Tdap, Flu, pneumonia, etc. Pediatrics- (per pediatric schedule for age) HPV if applicable
• Family History: Did I list for Parents, Grandparents, siblings, children?
• Review of Systems (SUBJECTIVE DATA): Did I include the systems related to my Chief Complaint and chronic conditions? Did I type detailed description? I did NOT use WNL. I was specific in my descriptions (see health assessment textbook). Did I remember this is what the patient says and not what I observed? Did I include the cardiovascular and respiratory system regardless of chief complaint?

Physical Exam: (OBJECTIVE DATA) This is what YOU see/touch/hear/smell

• Did I list the vital signs as the first thing in the objective section? Did I include the BMI for adults? Did I include the percentile for the ht, wt, bp etc for pediatrics?
• Did I examine the systems that are pertinent to the CC, HPI, and History. Did I describe what I observed? Did I never use WNL or normal? Did I describe what I observed during the physical exam?
• Did I include the systems in a list format?
• Did I include cardiovascular and respiratory systems regardless of cc?
• Did I delete the systems I did not review?

 

ASSESSMENT:

 

 

• Did I put my priority diagnosis in bold for EACH CC?
• Did I include at least 3 differentials(DD) after the priority diagnosis for EACH of my CC?
• Did I explain what each DD is, use references to explain and tell how you ruled in or ruled out each DD? (AND does your ROS and PE reflect this?)
• Did I include a reference citation for each diagnosis under the assessment area?
• Are my assessments concise and in a chart format?
• Did I put my differential diagnosis in order by priority?
• Did I provide a detailed rationale for each diagnosis? PRAC 6541: Primary Care of Adolescents and Children

Holistic care:

 

• Did I cover existing diagnoses and whether any changes need to be made?
• Did I include needed preventative care based on my patient’s age and risk factors?

PLAN:

• Did I include a treatment plan?
• Did I address if labs, x-rays, etc. were needed?
• Did I include a pharmacological plan and citation for EBP?
• Did I include non-pharmacological strategies?
• Did I discuss alternative therapies if applicable?
• Did I state when the patient needs a follow-up?
• Did I indication if any referrals or consultations were necessary or not necessary?
• Did I write a rationale based on evidence?
• Health Promotion: Did I address this area? Did I state what the patient/ family need to do to promote their health based on the USPTF for adults or Bright Futures for children? Did I document my citations?
• Disease Prevention: Did I do these based on recommendations from USPTF for adult’s or Bright Futures for children based on the patient’s age? Did I state what needs to be done to detect disease early…fasting lipid profile, mammography, colonoscopy, immunizations, etc? Did I cite the source?

 

 

 

REFLECTION:

• Did I state what I learned from this experience?
• Did I state what I would you do differently or if I would do everything the same and the rationale?
• Did I state if I either agreed or disagreed with my preceptor based on evidence (and cite references for EBP?
• Did I state what I would do if the person was insured versus if the person was not insured? Indicate how this would change your plan.
• Did I state the community resources in my area?

APA

• Do I have a minimum of 3 scholarly journal articles? (NONE OF WHICH ARE PATIENT EDUCATION SITES THAT I GOOGLED)
• Did I use at least 3-4 course resources?
• Do I have the paper in a neat format?
• Did I list my references in APA format? PRAC 6541: Primary Care of Adolescents and Children

 

 

 

 

 

 

 

 

 

 

 

Clinical Research Paper

B.  Discuss the impact of a clinical practice problem on the patient or patients and the organization it affects.

1.  Identify each of the following PICO components of the clinical practice problem:

•   P: patient, population, or problem

•   I: intervention

•   C: comparison

•   O: outcome

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2.  Develop an evidence-based practice (EBP) question based on the clinical practice problem discussed in part B and the PICO components identified in part B1. Clinical Research Paper

Note: Refer to the “Appendix B: Question Development Tool” web link for information on the creation of an EBP question.

C.  Select a research-based article that answers your EBP question from part B2 to conduct an evidence appraisal.

Note: The article you select should not be more than five years old.

1.  Discuss the background or introduction (i.e., the purpose) of the research-based article.

2.  Describe the research methodology used in the research-based article.

3.  Identify the level of evidence for the research-based article using the Johns Hopkins Nursing Evidence-Based Practice (JHNEBP) model.

Note: Refer to the “Appendix E: Research Evidence Appraisal Tool” web link for information on how to level a research-based article.

4.  Summarize how the researcher analyzed the data in the research-based article.

5.  Summarize the ethical considerations of the research-based article. If none are present, explain why.

6.  Identify the quality rating of the research-based article according to the JHNEBP model.

Note: Refer to the “Appendix E: Research Evidence Appraisal Tool” web link for information on how to establish the quality rating.

7.  Analyze the results or conclusions of the research-based article.

a.  Explain how the article helps answer your EBP question.

D.  Select a non-research-based article from a peer-reviewed journal that helps to answer your EBP question from part B2 to conduct an evidence appraisal.

Note: The article you select should not be more than five years old.

1.  Discuss the background or introduction (i.e., the purpose) of the non-research-based article.

2.  Describe the type of evidence (e.g., case study, quality improvement project, clinical practice guideline) used in the non-research-based article. Clinical Research Paper

3.  Identify the level of evidence in the non-research-based article using the JHNEBP model.

Note: Refer to the “Appendix F: Non-Research Evidence Appraisal Tool” web link for information on how to level the non-research-based article.

4.  Identify the quality rating of the non-research-based article according to the JHNEBP model.

5.  Discuss how the author’s recommendations in the non-research-based article help answer your EBP question.

E.  Recommend a practice change that addresses your EBP question using both the research-based and non-research-based articles you selected for part C and part D.

1.  Explain how you would involve three key stakeholders in supporting the practice change recommendation.

2.  Discuss one specific barrier you may encounter when implementing the practice change recommendation.

3.  Identify one strategy that could be used to overcome the barrier discussed in part E2.

4.  Identify one outcome (the O component in PICO) from your EBP question that can be used to measure the recommended practice change.

F.  Acknowledge sources, using APA-formatted in-text citations and references, for content that is quoted, paraphrased, or summarized.

G.  Demonstrate professional communication in the content and presentation of your submission.

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Community Health Nursing Assignment

After reviewing Module 1: Lecture Materials & Resources, discuss the following:

• Who are the clients in Community Health nursing?
• What government resources might they be eligible for ?
• What agencies are responsible for those resources? Community Health Nursing Assignment

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Submission Instructions:

• Your initial post should be at least 500 words, formatted and cited in current APA style with support from at least 2 academic sources.

Read

• Rector, C. & Stanley, M.J. (2022).
  • Chapter 1 – Introduction to Community Health Nursing
  • Chapter 2 – History and Evolution of Community Health Nursing
  • Chapter 3 – Setting the Stage for Community Health Nursing
  • Chapter 4 – Evidence-Based Practice and Ethics in Community Health Nursing
  • Chapter 5 – Transcultural Nursing in the Community
• American Psychological Association. (2020). Publication manual of the American Psychological Association (7th ed.). Community Health Nursing Assignment

Cultural, Spiritual, Nutritional, & Mental Health Disorders (Discussion 2)

For this , you will take on the role of a clinician who is building a health history for one of the following cases.:

SUBJECTIVE DATA:

Chief Complaint
(CC)“I came for my annual physical, but do not want to be a burden to my daughter.”

History of Present Illness (HPI)At-risk 86-year-old Asian male – who is physically and financially dependent on his daughter, a single mother who has little time or money for her father’s health needs.

PMH (Previous medical history) Hypertension (HTN), gastroesophageal reflux disease (GERD), b12 deficiency and chronic prostatitis

PSH S/P cholecystectomy

Drug HxCurrent Meds: Lisinopril 10mg daily, Prilosec 20mg daily, B12 injections monthly, and Cipro 100mg daily.

Allergies : none

Family history: none

REVIEW OF SYSTEMS (ROS)

General+ weight loss of 25 lbs over the past year; no recent fatigue, fever, or chills.  Cultural, Spiritual, Nutritional, & Mental Health Disorders (Discussion 2)

Head, Eyes, Ears, Nose & Throat (HEENT)No changes in vision or hearing, no difficulty chewing or swallowing.

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 NeckNo pain or injury

Respiratory: none

CV, GI: None

GUno urinary hesitancy or change in urine stream

Integumentmultiple bruises on his upper arms and back.

MS/Neuro+ falls x 2 within the last 6 months; no syncopal episodes or dizziness

OBJECTIVE DATA:

PE B/P 188/96; Pulse 89; RR 16; Temp 99.0; Ht 5,6; wt 110; BMI 17.8

HEENTAtraumatic, normocephalic, PERRLA, EOMI, arcus senilus bilaterally, conjunctiva and sclera clear, nares patent, nasopharynx clear, edentulous.

LungsCTA AP&L

CardS1S2 without rub or gallop

Abd benign, normoactive bowel sounds x 4

Ext no cyanosis, clubbing or edema

Integumentary multiple bruises in different stages of healing – on his upper arms and back.

NeuroNo obvious deformities, CN grossly intact II-XII

REQUIREMENTS:

 

1. Discuss the specific socioeconomic, spiritual, lifestyle, and other cultural factors related to the health of the patient you selected.
2. Utilizing the five assessment domains, which ones would you utilize on your patients in conducting a comprehensive nutritional assessment.
3. Discuss the functional anatomy and physiology of a psychiatric mental health patient. Which key concepts must a nurse know in order to assess specific functions?

Submision:

at least 500 words ( 2 complete pages of content) formatted and cited in current APA style 7 ed  with support from at least 3 academic sources which need to be journal articles or books from 2019 up to now. NO WEBSITES allowed for reference entry. Include doi, page numbers, etc. Plagiarism must be less than 10%. Cultural, Spiritual, Nutritional, & Mental Health Disorders (Discussion 2)