Soap Note 2 Chronic Conditions 2025

Soap Note 2 Chronic Conditions Soap Note Chronic Conditions (15 Points) Pick any Chronic Disease from Weeks 6-10 Soap notes will be uploaded to Moodle and put through TURN-It-In (anti-Plagiarism program) Follow the MRU Soap Note Rubric as a guide Turn it in Score must be less than 50% or will not be accepted for credit, must be your own work and in your own words. You can resubmit, Final submission will be accepted if less than 50%. Copy paste from websites or textbooks will not be accepted or tolerated. Please see College Handbook with reference to Academic Misconduct Statement Please use one of the templates provided to format your soap note. Keep these templates for future clinical rotations. SAMPLE Block format Soap Note  Template.docx Sample Soap Note Template.docx PATIENT INFORMATION Name: Mr. W.S. Age: 65-year-old Sex: Male Source: Patient Allergies: None Current Medications: Atorvastatin tab 20 mg, 1-tab PO at bedtime PMH: Hypercholesterolemia Immunizations: Influenza last 2018-year, tetanus, and hepatitis A and B 4 years ago. 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 Hx: No smoking history or illicit drug use, occasional alcoholic beverage consumption on social celebrations. Retired, widow, he lives alone. SUBJECTIVE: Chief complain : “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. ROS: CONSTITUTIONAL : Denies fever or chills. Denies weakness or weight loss. NEUROLOGIC : Headache and dizzeness 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 CONSTITUTIONAL : 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 0/10. General appearance: 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 Musculoskeletal: No pain to palpation. Active and passive ROM within normal limits, no stiffness. Integumentary: intact, no lesions or rashes, no cyanosis or jaundice. Assessment 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. Differential diagnosis: Ø Renal artery stenosis (ICD10 I70.1) Ø Chronic kidney disease (ICD10 I12.9) Ø Hyperthyroidism (ICD10 E05.90) Plan 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. These basic laboratory tests are: · CMP · Complete blood count · Lipid profile · Thyroid-stimulating hormone · Urinalysis · Electrocardiogram Ø Pharmacological treatment: The treatment of choice in this case would be: Thiazide-like diuretic and/or a CCB · Hydrochlorothiazide tab 25 mg, Initial dose: 25 mg orally once daily. Ø 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 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 · Evaluation with PCP in 1 weeks for managing blood pressure and to evaluate current hypotensive therapy. Urgent Care visit prn. · 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 Nursing Assignment Help 2025

The Nurse Leader and the Systems Development Life Cycle 2025

Part 1. The Systems Development Life Cycle for Implementation In a 2-page narrative, address the following: Explain each step of the systems development life cycle (SDLC) for a nursing informatics project. (1 page) Explain why nurse leaders should be involved in each step of the SDLC by identifying at least two ways that nurse leaders can contribute to best practices for implementation of nursing informatics projects. Be specific and provide examples. (1 page) Part 2. Job and Role Description of the Nurse in Systems Development and Implementation Develop a 1- to 2-page job and role description for a graduate level nurse to guide his/her participation on the implementation team for a new nursing documentation system. The job and role description should be based on the systems development life cycle (SDLC) stages and tasks, and should clearly define how this individual will participate in and impact each of the steps. Define the role of the nurse in the planning and defining requirements stage of the SDLC. (1–2 paragraphs) Define the role of the nurse in the analysis stage of the SDLC. (1–2 paragraphs) Define the role of the nurse in the design of the new system stage of the SDLC. (1–2 paragraphs) Define the role of the nurse in the implementation stage of the SDLC. (1–2 paragraphs) Define the role of the nurse in the testing and maintenance stages of the SLDC. (1–2 paragraphs)

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Practical Use of Theory 2025

All the information needed for the paper is attached. Paper is about the 2 questions bellow. please stay on topic and use information given. Read the 10 Caritas Processes™ on the Watson Caring Science Institute website which further elaborate on the carative factors listed in Box 8-4: Watson’s 10 Carative Factors located on p. 183 of Theoretical Basis for Nursing . Write a 250-word message in which you: 1-Reflect upon the caritas and address how these compare to your practice with patients and families, and relationships with other nurses and health care professionals. 2-Identify how you would use this theory to change your relationships with patients and others.

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psychiatric nursing 2025

plagiarism must be less than 15% . i need the assignment is 11 hours. Assignment: Assessing and Treating Clients with With Bipolar Disorder Bipolar disorder is a unique disorder that causes shifts in mood and energy, which results in depression and mania for clients. Proper diagnosis of this disorder is often a challenge for two reasons: 1) clients often present as depressive or manic, but may have both; and 2) many symptoms of bipolar disorder are similar to other disorders. Misdiagnosis is common, making it essential for you to have a deep understanding of the disorder’s pathophysiology. For this Assignment, as you examine the client case study in this week’s Learning Resources, consider how you might assess and treat clients presenting with bipolar disorder. Learning Objectives Students will: Assess client factors and history to develop personalized plans of bipolar therapy for clients Analyze factors that influence pharmacokinetic and pharmacodynamic processes in clients requiring bipolar therapy Evaluate efficacy of treatment plans Analyze ethical and legal implications related to prescribing bipolar therapy to clients across the lifespan .. The Assignment Examine Case Study: An Asian American Woman With Bipolar Disorder. You will be asked to make three decisions concerning the medication to prescribe to this client. Be sure to consider factors that might impact the client’s pharmacokinetic and pharmacodynamic processes. At each decision point stop to complete the following: Decision #1 Which decision did you select? Why did you select this decision? Support your response with evidence and references to the Learning Resources. What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources. Explain any difference between what you expected to achieve with Decision #1 and the results of the decision. Why were they different? Decision #2 Why did you select this decision? Support your response with evidence and references to the Learning Resources. What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources. Explain any difference between what you expected to achieve with Decision #2 and the results of the decision. Why were they different? Decision #3 Why did you select this decision? Support your response with evidence and references to the Learning Resources. What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources. Explain any difference between what you expected to achieve with Decision #3 and the results of the decision. Why were they different? you can use my sample/ edit or do a new assignment. you can edit or use my sample with same medication therapy. Walden University .. 6630n 2 Assessing and Treatment for Bipolar Disorder Patient Introduction Bipolar disorder is not an uncommon illness. It is a very chronic and severe mental disorder, affecting approximately 1-2% of the adult population. The signs and symptoms of bipolar disorder are different depending on the type of episode (i.e., manic or depressive). Each episode marks a critical change from the way a person usually acts and their typical mood, and can be characterized by a sudden change in the general attitude of the patient, the way the patient thinks and the behavior. 1 The changes will be sudden that it will be noticed by people around (Robert et al., 2017). This dangerous demonstrative unpredictability mood disorder can be found in all area of life, that is, from the poor to the rich, this disorder affects millions of people in all facets of life (Robert et al., 2017). Bipolar disorder can be seen mostly in the age starting at 25years or older, but it is not totally absent in the teenage age. It shows that about 2.6 percent of the population are diagnosed as bipolar. 3 (National Alliance on Mental Illness, 2017). If not well treated ,Bipolar disorder can be critical; 1 early identification of symptoms with an appropriate treatment plan may include psychotherapy, medications, a healthy lifestyle and a regular schedule will keep the patient healthy (National Alliance on Mental Illness. (2017). 1 The NP should have a good understand of this disorder to be able to take care of this the patient because of its long-term management and how it affects the health in totality (National Alliance on Mental Illness. (2017). 1 My focus of this paper will look into an Asian American Woman with a bipolar disorder, symptoms management, diagnosing the symptom, and the complete treatment. The paper will consider the most safe and appropriate options of treatment and the outcome as the treatment, and care. Decision Selected My patient is an Asian American woman age 39 years with 4 children and 3 ground children. The husband notices that sometimes she will be singing loud to the top of her voice and dancing not to the music she sang. In another time she will just fill like not doing anything and nothing will interest her, and she will lay on the bed for hours without going to the business she spent her years building and love so much. Patient is withdrawn and non-interactive. 4 She is diagnosed Bipolar disorder. 1 Decision # 1 Reason Selected My best treatment of choice for this disorder will be to begin Risperdal 2 mg orally twice a day. Risperdal is the best choice to treat bipolar disorder. (Lee et al., 2011). Risperdal called risperidone is in the chemical class benzisoxazole derivatives which are antipsychotic. It is an effective medication for bipolar disorder (Lee et al., 2011). The reasons of choosing Risperdal is because it is used to treat schizophrenia and the risperidone works with the brain to stabilize the brain (Lee et al., 2011). Risperidone rebalances dopamine and serotonin to improve thinking, mood, and behavior. Risperidone belongs to a class of drugs called atypical antipsychotics approved by U.S. Food and Drug Administration (FDA) The drug is also used to treat symptoms of bipolar disorder and irritability (NAMI, 2017). Expected Results We will need to have some subjective and objective changes. 1Patient should be able to verbalize changes within the first month of the treatment. During the next visit with the patient after one month, she is expected to express changes in the clarity of her brain. The freedom from indistinctness or ambiguity because of the medicine will help her to balance certain natural substances in her brain. She should also notice a change in her ability to concentrate on her activities (Lee et al., 2011). No side effects. Differences between Expected outcome and Actual outcome Patient came back after a month (4 WEEKS) and report that she experiences some improvement in the symptom including some improvement with concentration. My patient reported some drowsiness. 1 Drowsiness is one of the side effect of high dose of Risperdal. The genetic testing, reveals that she is positive for CYP2D6. Asians are more likely to have decreased CYP2D6 activity compared to Caucasians (Lee et al., 2011). I will reduce the dosage of this medication. 1 A positive outcome should be that there was a little bit of improvement in symptoms, patient able to sleep, more concentration. Patient and family report drowsiness during the day time which is one the side effect of high dose Risperdal. Decision Point Two Reason Selected The next best option is not to discontinue Risperdal, but to lower dose to Risperdal 1 mg orally at hours of sleep (HS) since expected outcome was not achieved based on decision one. My patient and , her family reported that patient has been drowsy during the day because of Risperdal 2mg. I will continue on Risperdal because the patient confirm improvement on the symptoms and the side effect observed was a regular adverse reaction because of her descendant background (American Psychiatric Association, 2017). The reduction to Risperdal 1mg BID to Risperdal 1 mg will be closely monitor. Expected Results Risperdal 1mg orally at bedtime is a reduced dosage from the 2mg which is expected to eliminate the drowsiness and toxicity in the patient Stahl, (2013). The patient is expected to continue to have decrease in the bipolar symptom. The effect of the medication should be observable and notice by the family member as a testimony (American Psychiatric Association, 2017). Differences between Expected outcome and Actual outcome During the patient four weeks follow up examination shows that the bipolar disorder symptom dissipated to noticeable level. This indicate a therapeutic effect of Risperdal 1mg at night brought about the therapeutic effect on the patient and patient is tolerating and adjusting to the medication in a positive way (Dean, 2017). The patient did not experience the drowsiness and there was no toxicity, therefore the expected result and the actual result were the same. Risperdal therapy will continue with this medication and the dosage, and a close monitoring will still be needed until the next four weeks appointment (Dean, 2017). Decision Point Three Decision Selected Risperdal 1mg orally at HS will be continued Reason for Selection The decision to continue with the medication was because the desire result, and the actual result are in pari-passu. To change the current medication or tamper with the dosage may offset the patient and thereby destabilize the rate of her healing (Dean, 2017). The patient is still under assessment and close monitoring continue until the next appointment date. Expected Results It is expected that the patient will increase in good mental stability and continue to maintain reduction in bipolar disorder symptom with the dosage of Risperdal 1mg at night (Robert et al., 2017). The patient is anticipated to having good sleep at night and well improve in her interaction with relatives and friends, with ability to concentrate on matters that concern her and carrier (Robert et al., 2017). Differences between Expected outcome and Actual outcome The therapeutic decision is working in this patient in accordance to the expectation. The treatment agrees with the standard way of treatment of an Asian descendant, the starting procedural treatment for bipolar disorder to the maintaining of such patient that are been positive for CYP2D6. The side effect of drowsiness in the day and toxicity is agreement with Asian descent (Robert et al., 2017). The patient will have to be place on the same medication till the next visit for examination. The actual result is that the medication is achieving the therapeutic effect that is needed by the patient (Dean, 2017). Ethical Considerations for Treatment plan Ethics demand that a patient should agree to treatment before it could be administering unto the patient. The law concerning patient’s preferences for treatment are overlook when the patient is in jeopardy of life threatening or severe psychiatric illness. Psychiatric advance directives are employing to make decision on the patient (Srivastava, 2011). When a practitioner treating a patient with bipolar is confronted with ethical conflicts of helping the patient to attain best result or their autonomy. The autonomy will be the choice of the practitioner (Srivastava, 2011). The law clearly stipulate that practitioners should always carefully consider what moral weight should be given to the values of doing well and avoiding harm (U.S. Food and Drug Administration, 2017). 2 Conclusion Psychiatric nurses should assess the function of the client not only during admission even during remission period and plan for rehabilitation services since functioning is a complex and demanding task. However, it is very important to bring back the client to his fullest possible level to normal life by planning effective psychoeducation about illness, communication training and teaching problem solving skills to client and family. 1 Many drugs are available for the treatment of bipolar disorder, but the professional will have to carefully select a medication that will be the best treatment for the patient. It is worth knowing that genetics influences the absorption of drugs, metabolism, excretion, and distribution. In the case study the Asian woman with positive CYP2D6 will exhibit a certain side effect which will not be in a patient with negative CYP2D6 (Dean, 2017). Therefore, the dosage and frequent of dispensing of drugs be based on the genetic testing (National Alliance on Mental Illness, 2017). The treatment of bipolar disorders in Asian descent must be handled carefully and in accordance with the Food and Drug Administration set guidelines (U.S. Food and Drug Administration, 2017). In conclusion the safety of the patient and the life of family and friends should be the paramount concern of the practitioners. References American Psychiatric Association. (2017). 1 Treatment of Patients with Bipolar Disorder. Retrieved from: 1http://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/bipolar.pdf Dean, L. (2017). 1 Risperidone Therapy and CYP2D6 Genotype. Retrieved from: 1 https://www.ncbi.nlm.nih.gov/books/NBK425795/ Lee, S. Y., Martins, S. S., Keyes, K. M., & Lee, H. B. (2011). 1 Mental Health Service Use by Persons of Asian Ancestry With DSM-IV Mental Disorders in the United States. Psychiatric Services (Washington, D.C.), 62(10), 1180–1186. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3698479/ Nami National Alliance on Mental Illness. (2017). 1 What Is Risperdal and What Does It Treat? Retrieved from: 1 https://www.nami.org/learn-more/treatment/mental-health-medications/risperidone (Risperdal). Robert, M., Keck, P., & David Solomon, D. (2017). 1 Bipolar disorder in adults: Choosing maintenance treatment. Retrieved from: 1https://www.uptodate.org/contents/bipolar-isorder-in-adults-choosing-maintenance-treatment Srivastava, S. (2011). Ethics Commentary: Bipolar Disorder: 1 Ethical Considerations in the Treatment of Bipolar Disorder. Retrieved from: 1 https://focus.psychiatryonline.org/doi/abs/10.1176/foc.9.4.foc461?journalCode=foc Stahl, S. M. (2013). 1 Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (4th ed.). New York, NY: Cambridge University Press. U.S. 1 Food and Drug Administration. (2017). 1 The Facts on Bipolar Disorder and FDA- Approved Treatments. Retrieved from: 1https://www.fda.gov/ForConsumers/ConsumerUpdates/ucm530107.htm

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