Plan of Care Assignment

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Plan of Care Assignment

SOAP Note Assignment

Click  here to download and analyze the case study for this week. Create a SOAP note for disease prevention, health promotion, and acute care of the patient in the clinical case. Your care plan should be based on current evidence and nursing standards of care.

Visit the online library and research for current scholarly evidence (no older than 5 years) to support your nursing actions. In addition, consider visiting government sites such as the CDC, WHO, AHRQ, Healthy People 2020. Provide a detailed scientific rationale justifying the inclusion of this evidence in your plan.

Next determine the ICD-10 classification (diagnoses). The International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-10-CM) is the official system used in the United States to classify and assign codes to health conditions and related information.

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Click here to access the codes. Plan of Care Assignment

Download the SOAP template to help you design a holistic patient care plan. Utilize the SOAP guidelines to assist you in creating your SOAP note and building your plan of care. You are expected to develop a comprehensive SOAP note based on the given assessment, diagnosis, and advanced nursing interventions. Reflect on what you have learned about care plans through independent research and peer discussions and incorporate the knowledge that you have gained into your patient’s care plan.  If the information is not in the provided scenario please consider it normal for SOAP note purposes, if it is abnormal please utilize what you know about the disease process and write what you would expect in the subjective and objective areas of your note.

Format

  • Your care plan should be formatted as a Microsoft Word document. Follow the current APA edition style. Your paper should be no longer than 3-4 pages excluding the title and the references and in 12pt font.

**Please delete this statement and anything in italics prior to submission to shorten the length Plan of Care Assignment

of your paper.

Patient Initials ______

Subjective Data: (Information the patient tells you regarding themselves: Biased Information):

Chief Compliant: (In patient’s exact words)

History of Present Illness: (Analysis of current problems in chronologic order using symptom

analysis [onset, location, frequency, quality, quantity, aggravating/alleviating factors, associated

symptoms and treatments tried]).

PMH/Medical/Surgical History: (Includes medications and why taking, allergies, other major

medical problems, immunizations, injuries, hospitalizations, surgeries, psychiatric history,

obstetric and history sexual history) Plan of Care Assignment.

Significant Family History: (Includes family members and specific inheritable diseases).

Social History: (Includes home living situation, marital history, cultural background, health

habits, lifestyle/recreation, religious practices, educational background, occupational history,

financial security and family history of violence).

Review of Symptoms: (Review each body system – This section you should place POSITIVE for…

information in the beginning then state Denies…). – General:; Integumentary:; Head:; Eyes: ;

ENT:; Cardiovascular:; Respiratory: ; Gastrointestinal:; Genitourinary:; Musculoskeletal:;

Neurological:; Endocrine:; Hematologic:; Psychologic: .

Objective Data:

Vital Signs: BP – ; P ; R ; T ; Wt. ; Ht. ; BMI .

Physical Assessment Findings: (Includes full head to toe review)

HEENT:

Lymph Nodes:

Carotids:

Lungs:

Heart:

Abdomen:

Genital/Pelvic:

Rectum:

Extremities/Pulses:

Neurologic:

Laboratory and Diagnostic Test Results: (Include result and interpretation.)

 

Assessment: (Include at least 3 priority diagnosis with ICD-10 codes. Please place in order of

priority.)

Plan of Care: (Addressing each dx with diagnostic and therapeutic management as well as

education and counseling provided).

 

 

NAME PLAN OF CARE 3

References

Intraoperative Nursing Management Paper

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Intraoperative Nursing Management Paper

Pearl Richards, 69 years of age, is a female patient who is in the operating room for a repair of an abdominal aortic aneurysm. The patient has a history of hypertension controlled with medications, osteoporosis, chronic obstructive pulmonary disease, and has smoked two packs of cigarettes per day for 40 years. (Learning Objectives 2, 6, and 9)  Intraoperative Nursing Management Paper

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  1. What nursing interventions are instituted to reduce the surgical risk factors related to the patient’s age?
  2. Explain the role of the nurse in providing patient safety measures during the intraoperative period.
  3. Intraoperative Nursing Management Paper

2. Mr. Bond is a 32-year-old Caucasian man who plays professional football. He was admitted for repair of a rotator cuff injury sustained in a game. In excellent shape, Mr. Bond has a muscular build and his body fat is 18%. Mr. Bond is transferred to the operating room, and the anesthesiologist begins to administer general anesthesia. During the induction of anesthesia, Mr. Bond develops tachycardia and dysrhythmias. His condition continues to deteriorate and he becomes severely hypotensive and exhibits decreased cardiac output. The anesthesiologist states that Mr. Bond is developing malignant hyperthermia. (Learning Objective 5)

  1. What risk factor does Mr. Bond have for malignant hyperthermia?
  2. What clinical manifestations of malignant hyperthermia does Mr. Bond demonstrate?
  3. Based on the patient’s condition, the surgical procedure is stopped and 100% oxygen is started. Additionally, a muscle relaxant and sodium bicarbonate are administered. What are the rationales for these medications? Intraoperative Nursing Management Paper

 

Integrated Prescriptive Pain Theories

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Integrated Prescriptive Pain Theories

Abstract

Several theoretical frameworks have been proposed to explain the physiological basis of pain, although none yet completely accounts for all aspects of pain perception. Here, we provide a historical overview of the major contributions, ideas, and competing theories of pain from ancient civilizations to Melzack and Wall’s Gate Control Theory of Pain.

The current definition of pain, established by the International Association for the Study of Pain (IASP) in 1986, defines pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of tissue damage, or both.” This definition is the culmination of centuries of ideas and work that have explored the concept of pain. Integrated Prescriptive Pain Theories

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A number of theories have been postulated to describe mechanisms underlying pain perception. These theories date back several centuries and even millennia (Kenins 1988; Perl 2007; Rey 1995). This review will mainly focus on theories postulated since the 17th century and then provide an overview of current thinking. The four most influential theories of pain perception include the Specificity (or Labeled Line), Intensity, Pattern, and Gate Control Theories of Pain

SPECIFICITY THEORY OF PAIN

The Specificity Theory refers to the presence of dedicated pathways for each somatosensory modality. The fundamental tenet of the Specificity Theory is that each modality has a specific receptor and associated sensory fiber (primary afferent) that is sensitive to one specific stimulus (Dubner et al. 1978). For instance, the model proposes that non-noxious mechanical stimuli are encoded by low-threshold mechanorecepetors, which are associated with dedicated primary afferents that project to “mechanoreceptive” second-order neurons in the spinal cord or brainstem (depending on the source of the input). These second-order neurons project to “higher” mechanoreceptive areas in the brain. Similarly, noxious stimuli would activate a nociceptor, which would project to higher “pain” centers through a pain fiber. These ideas have been emerging over several millennia but were experimentally tested and formally postulated as a theory in the 19th century by physiologists in Western Europe. Integrated Prescriptive Pain Theories

The Business of Pop Culture

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The Business of Pop Culture

Instructions

Analyze: Artifact of Popular Culture

Evaluation Title: The Business of Pop Culture

We have seen throughout this course how popular culture influences our attitudes, both positively and negatively. In this final paper, you will examine an artifact in pop culture to determine its message and effect.

For this assignment, select an artifact that, in your opinion, unfairly creates a negative bias or promotes a negative stereotype about one population of society. The pop-culture artifact can be a media source (song, movie, television program), a product, or other tangible associated with pop culture.  Provide a link to this artifact (or an image). Explain why you have selected this artifact and why you feel that this creates a negative bias. Describe how you would re-design or re-write the script of this artifact to change how others view this population. The Business of Pop Culture

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In your paper:

  • Provide a specific link to the pop culture artifact used for this paper or an image of the artifact.
  • Discuss the artifact in depth.  Explain the stereotypes or biases that you see being perpetuated in the artifact.
  • Discuss the role of popular culture in communicating harmful or incorrect stereotypes or biases.  Using the concepts, terminology, and ideas within Units 1-7, recommendations for how people can identify and correct views that are incorrect or harmful.
  • Re-design or re-write this artifact to change the way others could view this population without the negative bias.  Be sure to support this revised artifact with factual examples of the culture. The Business of Pop Culture

Specifications: 

Submit a 1200-1500 word essay addressing the questions above.

In your essay:

  • Be sure to structure your essay with an introduction paragraph that includes a thesis statement, well-organized supporting paragraphs, and a conclusion that reiterates the main points of your argument.
  • Your argument should be supported by reputable research cited in APA format both in the body of the paper and in your references section.

Helpful Resources:

  • Herzing University’s Tutoring and Writing Center
  • Grammar checker and writing help: https://www.grammarly.com/ (Links to an external site.)
  • Use the Herzing LIbrary to search for scholarly research sources. The Business of Pop Culture

Assessing A Healthcare Program

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Assessing A Healthcare Program

Program/policy evaluation is a valuable tool that can help strengthen the quality of programs/policies and improve outcomes for the populations they serve. Program/policy evaluation answers basic questions about program/policy effectiveness. It involves collecting and analyzing information about program/policy activities, characteristics, and outcomes. This information can be used to ultimately improve program services or policy initiatives.

Nurses can play a very important role assessing program/policy evaluation for the same reasons that they can be so important to program/policy design. Nurses bring expertise and patient advocacy that can add significant insight and impact. In this Assignment, you will practice applying this expertise and insight by selecting an existing healthcare program or policy evaluation and reflecting on the criteria used to measure the effectiveness of the program/policy.

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To Prepare:

· Review the Healthcare Program/Policy Evaluation Analysis Template provided in the Resources.

· Select an existing healthcare program or policy evaluation or choose one of interest to you and get approval to use it from your Instructor.

· Review the healthcare program or policy evaluation and reflect on the criteria used to measure the effectiveness of the program or policy described. Assessing A Healthcare Program

The Assignment: (2–3 pages)

Based on the program or policy evaluation you selected, complete the Healthcare Program/Policy Evaluation Analysis Template. Be sure to address the following:

· Describe the healthcare program or policy outcomes.

· How was the success of the program or policy measured?

· How many people were reached by the program or policy selected?

· How much of an impact was realized with the program or policy selected?

· At what point in program implementation was the program or policy evaluation conducted?

· What data was used to conduct the program or policy evaluation?

· What specific information on unintended consequences was identified?

· What stakeholders were identified in the evaluation of the program or policy? Who would benefit most from the results and reporting of the program or policy evaluation? Be specific and provide examples.

· Did the program or policy meet the original intent and objectives? Why or why not?

· Would you recommend implementing this program or policy in your place of work? Why or why not?

· Identify at least two ways that you, as a nurse advocate, could become involved in evaluating a program or policy after 1 year of implementation. Assessing A Healthcare Program

Evidence-based discharge teaching is critical in promoting health

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Evidence-based discharge teaching is critical in promoting health

Evidence-based discharge teaching is critical in promoting health and impacting readmissions. You will address Tina Jones’ diagnoses; asthma, dehydration, and wound infection, providing education that will support adherence and prevent readmission.  Provide clear guidance for wound care, infection control, medications, diet, blood sugar monitoring, activity, and follow-up that will optimize her health.

Discharge teaching on Tina Jones on the following: Evidence-based discharge teaching is critical in promoting health

Diabetics

Addresses all areas of the diagnosis, including pathophysiology, risk factors, and health promotion using current EBP in a patient centered manner demonstrating caring behaviors with use of therapeutic communication.

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ASTHMA

Addresses all areas of the diagnosis, including pathophysiology, risk factors, and health promotion using current EBP in a patient centered manner demonstrating caring behaviors with use of therapeutic communication.  Evidence-based discharge teaching is critical in promoting health

DEHYDRATION

Addresses all areas of the diagnosis, including pathophysiology, risk factors, and health promotion

nursing current EBP in a patient centered manner demonstrating caring behaviors with use of therapeutic communication

INFECTION

Addresses all areas of the diagnosis, including pathophysiology, risk factors, and health promotion using current EBP in a patientcentered manner demonstrating caring behaviors with use of therapeutic communication.

WOUND CARE

Thorough instruction on asepsis, wound care and equipment using current EBP in a patient-centered manner demonstrating caring behaviors with use of therapeutic communication Evidence-based discharge teaching is critical in promoting health

MEDICATION

Thorough instruction on medications, including indication, dosing, adverse effects, adherence, and administration using EBP in a patient-centered manner demonstrating caring behaviors with use of therapeutic communication.

ACTIVITY

Thorough instruction on activity, including bathing, equipment, and safety using EBP in a patientcentered manner demonstrating caring behaviors with use of therapeutic communication

DIET

Thorough instruction on proper diet for diabetes management, including counting carbohydrates, hypo- and hyperglycemia, and lifestyle changes using EBP in a patient-centered manner demonstrating caring behaviors with use of therapeutic communication

FOLLOW UP

Thorough instruction on instructions on follow-up plan, including appointments and warning signs of potential problems using EBP in a patient-centered manner demonstrating caring behaviors with use of therapeutic communication.

No errors in APA, Spelling, and Punctuation. Provides two or more references.

3-4 pages Evidence-based discharge teaching is critical in promoting health

What are your assumptions or underlying beliefs about:      Nurses?      Patients?      Other healthcare providers?      Communities? 4. Definitions and examples of  th

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. Introduction that includes who you are (nursing student) and where you practice nursing. 2. Definition of Nursing Why does nursing exist? Why do you practice nursing? 3. What are your assumptions or underlying beliefs about: Nurses? Patients? Other healthcare providers? Communities? 4. Definitions and examples of  the major domains (person, health, and environment) of nursing 5. Summary that includes: a. How are the domains connected? b. What is your vision of nursing for the future? c. What are the challenges that you will face as a nurse? d. What are your goals for professional development? Write your personal philosophy of nursing. The paper should be 3 pages typewritten double spaced  following APA style guidelines. The paper will be checked for plagiarism.
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