Nursing homework help

Episodic/Focused SOAP Note Template

Patient Information:

Initials, Age, Sex, Race

S.

CC (chief complaint) a BRIEF statement identifying why the patient is here – in the patient’s own words – for instance “headache”, NOT “bad headache for 3 days”. Nursing homework help

HPI: This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. Use LOCATES Mnemonic to complete your HPI. You need to start EVERY HPI with age, race, and gender (e.g., 34-year-old AA male). You must include the seven attributes of each principal symptom in paragraph form not a list. If the CC was “headache”, the LOCATES for the HPI might look like the following example:

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Location: head

Onset: 3 days ago

Character: pounding, pressure around the eyes and temples

Associated signs and symptoms: nausea, vomiting, photophobia, phonophobia

Timing: after being on the computer all day at work

Exacerbating/ relieving factors: light bothers eyes, Aleve makes it tolerable but not completely better

Severity: 7/10 pain scale

Current Medications: include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.

Allergies: include medication, food, and environmental allergies separately (a description of what the allergy is ie angioedema, anaphylaxis, etc. This will help determine a true reaction vs intolerance).

PMHx: include immunization status (note date of last tetanus for all adults), past major illnesses and surgeries. Depending on the CC, more info is sometimes needed

Soc Hx: include occupation and major hobbies, family status, tobacco & alcohol use (previous and current use), any other pertinent data. Always add some health promo question here – such as whether they use seat belts all the time or whether they have working smoke detectors in the house, living environment, text/cell phone use while driving, and support system.

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.

ROS: cover all body systems that may help you include or rule out a differential diagnosis You should list each system as follows: General: Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe.

Example of Complete ROS:

GENERAL:  Denies weight loss, fever, chills, weakness or fatigue.

HEENT:  Eyes: Denies visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat:  Denies hearing loss, sneezing, congestion, runny nose or sore throat.

SKIN:  Denies rash or itching.

CARDIOVASCULAR:  Denies chest pain, chest pressure or chest discomfort. No palpitations or edema.

RESPIRATORY:  Denies shortness of breath, cough or sputum.

GASTROINTESTINAL:  Denies anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.

GENITOURINARY:  Burning on urination. Pregnancy. Last menstrual period, MM/DD/YYYY.

NEUROLOGICAL:  Denies headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.

MUSCULOSKELETAL:  Denies muscle, back pain, joint pain or stiffness.

HEMATOLOGIC:  Denies anemia, bleeding or bruising.

LYMPHATICS:  Denies enlarged nodes. No history of splenectomy.

PSYCHIATRIC:  Denies history of depression or anxiety.

ENDOCRINOLOGIC:  Denies reports of sweating, cold or heat intolerance. No polyuria or polydipsia.

ALLERGIES:  Denies history of asthma, hives, eczema or rhinitis.

O.

Physical exam: From head-to-toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History. Do not use “WNL” or “normal.” You must describe what you see. Always document in head to toe format i.e. General: Head: EENT: etc.

Diagnostic results: Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines)

A.

Differential Diagnoses (list a minimum of 3 differential diagnoses).Your primary or presumptive diagnosis should be at the top of the list. For each diagnosis, provide supportive documentation with evidence based guidelines.

This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.

References

You are required to include at least three evidence based peer-reviewed journal articles or evidenced based guidelines which relates to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 7^th edition formatting.

Nursing homework help

Module 5/ Writing for Nurses.

Review alphanumeric outlines at https://owl.purdue.edu/owl/purdue_owl.html

Remember when you are creating an outline that each heading MUST have a minimum of two (2) subheadings.  The rationale lies in the thinking that if you cannot think of at least two items to flesh out a specific heading then the information in that one subheading is really part of the topic in the heading. Nursing homework help

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1. Introduction to topic
   II. Topic:  Abuse of alcohol and opioids can affect individuals economically, physically, and emotionally
2. Economically
   1. Alcohol
3. Cost to buy alcohol
   b. Cost of legal proceedings
   c. Cost of property damage
4. Opioids
5. Cost of legal prescriptions
   b. Cost of illegal purchases
   c. Cost of legal proceedings
6. Physical effects
   1. Alcohol
7. Poor nutrition
   b. Liver damage
   c. Depression
8. Opioids
9. Infection from use of dirty needles
   b. Tolerance and dependence
   c. Depression
10. Emotional effects

lll. Next topic, etc.

.

Selecting Credible Sources

University of California San Diego Department of Psychology. (2018). What types of references are appropriate? https://psychology.ucsd.edu/undergraduate-program/undergraduate-resources/academic-writing-resources/writing-research-papers/appropriate-references.html

University of Maryland. (2018). Is my source credible?  http://sites.umuc.edu/library/libhow/credibility.cfm

Writing for Nurses/Module 5 Outline directions.

Overview:

Creating an outline of a paper assists the author in organizing the content of the paper.  It allows the author the opportunity to discover what ideas fit together well and which ones need additional clarification.  The more detailed the outline the easier it will be to write the final paper.

Review first sample outline at https://owl.purdue.edu/owl/purdue_owl.html

• Use Roman numerals for the main headings in the outline (I, II, III, IV)
  • Capital letters are used for the subheadings (A, B, C, D)
  • If another set of subheadings is needed use 1, 2, 3, 4
  • The next subheading would be lowercase letters, e.g., a, b, c, d

Note: There can be no fewer than two (2) subheadings beneath any heading. See the example in the Instructional Materials folder for Module 5. Nursing homework help

Instructions

1. You are to create an alphanumeric outline of the final paper.
2. Main headings will include one heading titled Introduction and one titled Conclusion.  Other main headings will address major concepts in your thinking.
3. The outline is to provide the logical progression of the ideas and points you will make in the final paper. Items do not need to be in complete sentences.
4. The outline is to have at least two (2) peer reviewed references.  You do NOT need to include in-text citations in the outline, but you will need to include a reference list on a separate page to give credit to the original author of the information. References MUST be in proper APA Manual 7th edition
5. Include a properly formatted student APA Manual 7th edition title page

• Click on the link titled ” M5 A1: OUTLINE OF FINAL PAPER – SUBMISSION AREA” to submit the assignment.
• Refer to Rubric for evaluation guidelines
• Points: 20
• Due: See Course Calendar/Checklist

Note: You will have three (3) attempts to submit a written assignment, only the final attempt will be graded. For each attempt you will receive a SafeAssign originality report. This will give you a chance to correct the assignment based on the SafeAssign score. Click here to view instructions on how to interpret your SafeAssign originality report.

Kindly note: If a submission has been made for more than 48 hours without a re-submission, it will be considered final and will be subject to being graded.

Nursing homework help

• With regard to the Episodic note case study provided:
  • Review this week’s Learning Resources, and consider the insights they provide about the case study.
  • 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? Nursing homework help
  • Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.

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The Assignment

1. Analyze the subjective portion of the note. List additional information that should be included in the documentation.
2. Analyze the objective portion of the note. List additional information that should be included in the documentation.
3. Is the assessment supported by the subjective and objective information? Why or why not?
4. What diagnostic tests would be appropriate for this case, and how would the results be used to make a diagnosis?
5. 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. Nursing homework help

In this Assessment, 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. Just add in what you want to this case to make it unique to you. Do not use NA or normal.

ABDOMINAL ASSESSMENT

Subjective:

• CC: “My stomach hurts, I have diarrhea and nothing seems to help.”

• HPI: JR, 47 yo WM, complains of having generalized abdominal pain that started 3 days ago. He has not taken any medications because he did not know what to take. He states the pain is a 5/10 today but has been as much as 9/10 when it first started. He has been able to eat, with some nausea afterwards.

• PMH: HTN, Diabetes, hx of GI bleed 4 years ago

• Medications: Lisinopril 10mg, Amlodipine 5 mg, Metformin 1000mg, Lantus 10 units qhs

• Allergies: NKDA

• FH: No hx of colon cancer, Father hx DMT2, HTN, Mother hx HTN, Hyperlipidemia, GERD

• Social: Denies tobacco use; occasional etoh, married, 3 children (1 girl, 2 boys)

Objective:

• VS: Temp 99.8; BP 160/86; RR 16; P 92; HT 5’10”; WT 248lbs

• Heart: RRR, no murmurs

• Lungs: CTA, chest wall symmetrical

• Skin: Intact without lesions, no urticaria

• Abd: soft, hyperactive bowel sounds, pos pain in the LLQ

• Diagnostics: ?

Assessment:

• Left lower quadrant pain

• Gastroenteritis

PLAN:

Name: Tina Jones

Section:

Week 4                

Shadow Health Digital Clinical Experience Health History Documentation

SUBJECTIVE DATA: Include what the patient tells you, but organize the information.

Chief Complaint (CC):

History of Present Illness (HPI):

Medications:

Allergies:

Past Medical History (PMH):

Past Surgical History (PSH):

Sexual/Reproductive History:

Personal/Social History:

Immunization History:

Health Maintenance:

Significant Family History (Include history of parents, maternal/paternal Grandparents, siblings, and children):

Review of Systems: From head-to-toe, include each system that covers the Chief Complaint, History of Present Illness, and History).Remember that the information you include in this section is based on what the patient tells you. To ensure that you include all essentials in your case, refer to Chapter 2 of the Sullivan text.

General: Include any recent weight changes, weakness, fatigue, or fever, but do not restate HPI data here.

                HEENT:

Neck:

                Breasts:

                Respiratory:

                Cardiovascular/Peripheral Vascular:

                Gastrointestinal:

                Genitourinary:

                Musculoskeletal:

                Psychiatric:

                Neurological:

                Skin:

                Hematologic:

                Endocrine: