http://www.nhlbi.nih.gov/health/dci/Diseases/HeartAttack/HeartAttack_WhatIs.html 

 Every unit will contain web sites that will expand the information you will have available on the subject. You will be expected to visit one or more of these web sites and submit an essay in the essay assignment about the information in the website. Complete this assignment by writing a 2 paragraph essay (not less than 120 words) about something you learned from one or more of the web sites. Enter the essay in the submission box and submit it. 

TITLE: NASAL FRACTURE

EXAMPLE: SOAP NOTE

  

Soap Note # Main Diagnosis ( Exp: H&P Note #3 DX: Hypertension)

Student Name

Miami Regional University

Date of Encounter:

Preceptor/Clinical Site:

Clinical Instructor: Dr. Rafael Camejo

  

Soap Note # Main Diagnosis ( Exp: Soap Note #3 DX: Hypertension)

PATIENT INFORMATION

Name: Mr. DT

Age: 68-year-old

Gender at Birth: Male

Gender Identity: Male

Source: Patient

Allergies: PCN, Iodine

Current Medications: 

· Atorvastatin tab 20 mg, 1-tab PO at bedtime

· ASA 81mg po daily

· Multi-Vitamin Centrum Silver

PMH: Hypercholesterolemia

Immunizations: Influenza last 2018-year, tetanus, and hepatitis A and B 4 years ago.

Preventive Care: Coloscopy 5 years ago (Negative) 

Surgical History: Appendectomy 47 years ago.

Family History: Father- died 81 does not report information

 Mother-alive, 88 years old, Diabetes Mellitus, HTN

Daughter-alive, 34 years old, healthy

Social History: No smoking history or illicit drug use, occasional alcoholic beverage consumption on social celebrations. Retired, widow, he lives alone.

Sexual Orientation: Straight

Nutrition History: Diets off and on, Does not each seafood 

Subjective Data:

Chief Complaint: “headaches” that started two weeks ago

Symptom analysis/HPI:

The patient is 65 years old male who complaining of episodes of headaches and on 3 different occasions blood pressure was measured, which was high (159/100, 158/98 and 160/100 respectively). Patient noticed the problem started two weeks ago and sometimes it is accompanied by dizziness. He states that he has been under stress in his workplace for the last month. Patient denies chest pain, palpitation, shortness of breath, nausea or vomiting.

Review of Systems (ROS)

CONSTITUTIONAL: Denies fever or chills. Denies weakness or weight loss. NEUROLOGIC: Headache and dizziness as describe above. Denies changes in LOC. Denies history of tremors or seizures. 

HEENT: HEAD: Denies any head injury, or change in LOC. Eyes: Denies any changes in vision, diplopia or blurred vision. Ear: Denies pain in the ears. Denies loss of hearing or drainage. Nose: Denies nasal drainage, congestion. THROAT: Denies throat or neck pain, hoarseness, difficulty swallowing.

RESPIRATORY: Patient denies shortness of breath, cough or hemoptysis.

CARDIOVASCULAR: No chest pain, tachycardia. No orthopnea or paroxysmal nocturnal

dyspnea.

GASTROINTESTINAL: Denies abdominal pain or discomfort. Denies flatulence, nausea, vomiting or

diarrhea.

GENITOURINARY: Denies hematuria, dysuria or change in urinary frequency. Denies difficulty starting/stopping stream of urine or incontinence.

MUSCULOSKELETAL: Denies falls or pain. Denies hearing a clicking or snapping sound.

SKIN: No change of coloration such as cyanosis or jaundice, no rashes or pruritus.

Objective Data:

VITAL SIGNS: Temperature: 98.5 °F, Pulse: 87, BP: 159/92 mmhg, RR 20, PO2-98% on room air, Ht- 6’4”, Wt 200 lb, BMI 25. Report pain 2/10.

GENERAL APPREARANCE: The patient is alert and oriented x 3. No acute distress noted. NEUROLOGIC: Alert, CNII-XII grossly intact, oriented to person, place, and time. Sensation intact to bilateral upper and lower extremities. Bilateral UE/LE strength 5/5.

HEENT: Head: Normocephalic, atraumatic, symmetric, non-tender. Maxillary sinuses no tenderness. Eyes: No conjunctival injection, no icterus, visual acuity and extraocular eye movements intact. No nystagmus noted. Ears: Bilateral canals patent without erythema, edema, or exudate. Bilateral tympanic membranes intact, pearly gray with sharp cone of light. Maxillary sinuses no tenderness. Nasal mucosa moist without bleeding. Oral mucosa moist without lesions,. Lids non-remarkable and appropriate for race.

Neck: supple without cervical lymphadenopathy, no jugular vein distention, no thyroid swelling or masses.

CARDIOVASCULAR: S1S2, regular rate and rhythm, no murmur or gallop noted. Capillary refill < 2 sec.

RESPIRATORY: No dyspnea or use of accessory muscles observed. No egophony, whispered pectoriloquy or tactile fremitus on palpation. Breath sounds presents and clear bilaterally on auscultation.

GASTROINTESTINAL: No mass or hernia observed. Upon auscultation, bowel sounds present in all four quadrants, no bruits over renal and aorta arteries. Abdomen soft non-tender, no guarding, no rebound no distention or organomegaly noted on palpation

MUSKULOSKELETAL: No pain to palpation. Active and passive ROM within normal limits, no stiffness.

INTEGUMENTARY: intact, no lesions or rashes, no cyanosis or jaundice.

ASSESSMENT:

Main Diagnosis

Essential (Primary) Hypertension (ICD10 I10): Given the symptoms and high blood pressure (156/92 mmhg), classified as stage 2. Once the organic cause of hypertension has been ruled out, such as renal, adrenal or thyroid, this diagnosis is confirmed (Codina Leik, 2015). Diagnosis is based on the clinical evaluation through history, physical examination, and routine laboratory tests to assess risk factors, reveal identifiable causes and detect target-organ damage, including evidence of cardiovascular disease (Domino et al,. 2017).

Differential diagnosis:

Ø Renal artery stenosis (ICD10 I70.1)

Ø Chronic kidney disease (ICD10 I12.9)

Ø Hyperthyroidism (ICD10 E05.90)

PLAN:

Labs and Diagnostic Test to be ordered:

· CMP

· Complete blood count (CBC)

· Lipid profile

· Thyroid-stimulating hormone (TSH)

· Urinalysis with Micro

· Electrocardiogram (EKG 12 lead)

Pharmacological treatment: 

· Hydrochlorothiazide tab 25 mg, Initial dose: 25 mg orally once daily. 

· Lisinopril 10mg PO Daily

Non-Pharmacologic treatment: 

· Weight loss

· Healthy diet (DASH dietary pattern): Diet rich in fruits, vegetables, whole grains, and low-fat dairy products with reduced content of saturated and trans l fat

· Reduced intake of dietary sodium: <1,500 mg/d is optimal goal but at least 1,000 mg/d reduction in most adults

· Enhanced intake of dietary potassium

· Regular physical activity (Aerobic): 90–150 min/wk

· Tobacco cessation

· Measures to release stress and effective coping mechanisms.

Education

· Provide with nutrition/dietary information.

· Daily blood pressure monitoring log at home twice a day for 7 days, keep a record, bring the record on the next visit with her PCP

· Instruction about medication intake compliance. 

· Education of possible complications such as stroke, heart attack, and other problems.

· Patient was educated on course of hypertension, as well as warning signs and symptoms, which could indicate the need to attend the E.R/U.C. Answered all pt. questions/concerns. Pt verbalizes understanding to all

Follow-ups/Referrals

· Follow up appointment 1 weeks for managing blood pressure and to evaluate current hypotensive therapy.

· No referrals needed at this time.

References

Domino, F., Baldor, R., Golding, J., Stephens, M. (2017). The 5-Minute Clinical Consult 2017

(25th ed.). Print (The 5-Minute Consult Series).

Codina Leik, M. T. (2014). Family Nurse Practitioner Certification Intensive Review (2nd ed.). 

ISBN 978-0-8261-3424-0

NOTE: PLEASE APA FORMAT OF THE REFERENCE, AND ORIGINAL

Nurses must be able to knowledgeably plan services for individuals, families and the community.  In order to effectively plan, it is essential that you are aware of the resources specific to the community a client resides in to allow for identification of health-related resources and to understand gaps in services. A windshield survey is conducted from a car and provides a visual overview of a community. Conditions and trends in the community that could affect the health of the population should be noted. This data provides background and context for working with individuals and families in their community.  Information gathered from this survey should be added to this template.  Please complete and copy & paste to the homework section no later than 2/22/20.  Make sure to include data (i.e. statistical, informational, geographic), along with a reference page. 

Each response 200 words

1) 

Learning is the process of taking in new information and applying it to a situation or demonstrating it to others.  The ability to learn is possessed by humans, and animals; some learning is immediate, and at times a single event can induce something will never forget (e.g. being burned by a hot stove), but much skill and knowledge accumulates from repeated experiences.  My presentation will utilize more than one way of learning, I will have video, audio; from my power point slide, handouts, pictures, and demonstration activities.  The handout will be in English and Spanish, the power point slide will be shown slowly and interpreted by my selected leader to state what I say in Spanish.  

            During the past few weeks, I have interviewed several people from different age groups and received some feed back on their level of understanding.  I will make sure my handouts and infographics are very simple and not overly crowded.  Upon setting my tables up for my audience, I am going to make sure the groups are mixed amongst age group.  All ages at each table, not allowing all teens at one table or all adults; etc.  Women, men, and young adults at each table is my goal to establish a more conducive learning environment.   

            Having my handouts in simple colorful form, will grasps my audience attention; but more importantly having it in the language they understand best is going to be more productive and increase my chances of delivering my message effectively.  I am going to show pictures of the more commonly used blood pressure medication and show them where they can research and learn about the blood pressure pills, they are prescribed.  I will work on decreasing the use of Google to find out about hypertension and blood pressure medications; by giving them medical website that are designed by medical physicians.

            One of my goals, that I am still working on; is the importance of investing in a blood pressure monitor, if they can afford one.  I will also give them a list of stores that usually have a blood pressure station, such as Walmart and CVS.  I am going to also discuss with the apartment manager the possibility of keeping a blood pressure monitor in the office where residents and come in and utilize it to take their blood pressure on site.  Anyone that gets an extremely high reading, will be encouraged to come next door to the hospital.     

Clark, M. J. (2015). Population and community health nursing (6th ed.). Boston, MA: Pearson

2) 

This is very delicate part of the project because there many variables. People learn in a variety of different ways and situations. It is important to keep in mind that in order to reach the majority of people in the community it is good to try to be respectful and understanding to everyone’s needs. When preparing my presentation, I will take into consideration my audience. My audience will predominately be younger individuals. The presentation should be focused with that in mind. Young people will have different focuses in relation to older adults. Adolescents have different reasons for drug use from adults. Adolescents will often try drugs in a social situation. They feel pressured to do something they normally would not do. Friends that are often using drugs and want to be like them. Adults on the other hand use drugs to deal with stress or anxiety. Another reason Adults use is to deal with chronic pain. What ever their incentive for using drugs, it is unhealthy and dangerous. What is needed is education. They need to understand what these substances are doing to their body’s and how they can get help. In order to get the message to them delivery of the information must be interesting and pertinent to the audience. The presentation should be given in a way that all can understand the underlying meaning of what is being talked about. Content must be appropriate for the listening audience.

Another important factor in the presentation is to maintain interest. Time plays a big point of presentations. Having the presentation last for a long time presents a risk of effectiveness and success (Wellstead, Whitehurst, Gundogan & Agha, 2017). It is also important to have the audience interact during the presentation. This ensures that material is being heard and allows for response from those present.  The presenter should attempt to maintain eye contact with the group. The presenter should have attractive visual aids. It is helpful that speaker use different voice techniques to maintain interest in the topic. It is always a good idea to finish with a recap and clarify information previously discussed. Finally, asking if there are any questions is always a good idea to have handouts and pamphlets. These will summarize the main points of the presentation. It will also serve as reference material. Names of treatment centers and counseling opportunities will be available at a quick glance.  This information can be helpful to the user, family or friends.

                                                                                References

Wellstead, G., Whitehurst, K., Gundogan, B., & Agha, R. (2017). How to deliver an oral

presentation. International journal of surgery. Oncology, 2(6), e25.

https://doi.org/10.1097/IJ9.0000000000000025