In this assignment, you will analyze a SOAP 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.

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, hyperctive bowel sounds, pos pain in the LLQ

· Diagnostics: None

ASSESSMENT:

· Left lower quadrant pain

· Gastroenteritis

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

To prepare:

With regard to the SOAP 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?

· Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.

To complete:

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?

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 3 different references from current evidence based literature 

Conduct a health assessment of a population of your choice. Explain the process and summarize the results.

Effective communication is one of the most critical skills a health care  provider can master. Nurses communicate to a variety of individuals  with a range of educational levels who come from diverse settings.

Suggested Resources

To help you prepare for this assessment, review the resources you  used and the assessments you completed in BSN-FP4002, BSN-FP4010, and  BSN-FP4014.

Preparation

To prepare for this assessment, you will need to think about  changes you feel are needed to address a problem either within nursing  as a professional field or within the organization where you work.  Narrow down your options by considering which change would best be  undertaken by an interprofessional team. Some examples for you to  consider might include:

• The use of mobile and portable technology to support patients.
• Using evidence-based practice (EBP) to improve patient care.
• Increasing patient safety and quality of care.
• The use of medical technology such as genes and stem cells, or robots in the OR.
• Addressing the nursing shortage now and into the future.
• Improving the work environment (providing calm, supportive spaces  for nurses; improved dialog between health care professionals).
• Better safety for nurses at work (violence, spreading diseases, physical injury).
• Substance abuse by health care professionals.

Or you can narrow the scope to an issue within your own organization:

• Developing a mobility program for an inpatient unit.
• Implementing “smart” technology to assist in patient monitoring.
• Creating a mentoring program to attract and retain nurses.
• Implementing protocols for infection control and/or treatment of an epidemic.
• Developing a plan to eliminate physical violence and verbal abuse in the workplace.
• Other.

Once you have selected an issue to address, look for scholarly and  professional articles that focus on the problem, the needed change, and  how interprofessional teams can work together to drive change.

Requirements

Lately you have noticed the need for changes within your  organization that would advance the field of nursing. You have decided  to develop a proposal and submit it to executive leadership. Format this  assessment as a professional proposal. You may want to look at how  proposals are drafted within your organization and follow that format.  You will still need a references page; follow APA guidelines for in-text  citations and references.

Address the following in your proposal:

• Briefly describe the problem and how it impacts the organization, patients, and/or the nursing profession.
• Describe possible evidence-based interventions for the problem.
• Analyze potential barriers and resistance to change that might come from the organization, patients, and/or colleagues.
• Describe strategies to overcome barriers and resistance to change.
• Develop a plan to implement evidence-based interventions. What steps would you take? What resources might you need?
• Identify other health care professionals to enlist as team members to help drive change in the organization.

Your completed assessment should be 4–6 pages in length, not  including title page and references page. Support your statements and  intervention plan with references to and citations for at least four  scholarly or professional resources.

Additional Requirements

• Include a title page and references page.
• Reference at least four current scholarly or professional resources.
• Use APA format for citations and references.
• Use Times New Roman font, 12 point.
• Double space.

Conduct a health assessment of a population of your choice. Explain the process and summarize the results.

Effective communication is one of the most critical skills a health care  provider can master. Nurses communicate to a variety of individuals  with a range of educational levels who come from diverse settings.

Conduct a health assessment of a population of your choice as you complete the following:

1. Describe the key elements that make up a health assessment at each of the following levels:      
   1. Community.
   2. Group.
   3. Individual.
2. Explain the process for completing a comprehensive health assessment.
3. Summarize the findings of the health assessment you conducted. Be  sure you include a brief description of the population you selected.

Additional Requirements

• Format: Include a title page and reference. Use APA style and formatting.
• Length: This assessment should be approximately 3–5 pages in length. 
• References: Cite at least three current scholarly or professional resources.
• Font: Use double-spaced, 12-point, Times New Roman font.

 

Write a 2-3 page APA formatted paper (not including cover sheet or reference page) utilizing a minimum of three resources based on the case scenario below. You may opt to do a power point presentation or Prezi with a minimum of 10 – 15 slides (not including cover sheet or reference slide) instead of the written paper.

Scenario: A gravida two, para-one 34 year old woman comes into the office for pre-natal care. She is 28 weeks pregnant. Her blood pressure is 160/90 with a weight of 220 lbs and a height of 5’1. Her previous blood pressure at her visit 4 weeks ago was 122/ 78. Her previous weight was 210 lbs. She reports a history of gestational diabetes. Her fasting glucose is 108 with an A1C of 6.0.

What focused assessments would you expect the practical nurse to perform? What important data would need to be communicated to her health care team?

                                                            Rubric

  

Scenario: A gravida two, para-one 34 year old woman comes into the office for pre-natal care. She is 28 weeks pregnant. Her blood pressure is 160/90 with a weight of 220 lbs and a height of 5’1. Her previous blood pressure at her visit 4 weeks ago was 122/ 78. Her previous weight was 210 lbs. She reports a history of gestational diabetes. Her fasting glucose is 150. 

What focused assessments would you expect the practical nurse to perform? What important data would need to be communicated to her health care team?

                                      Scoring Rubric

  

Care of a patient with prenatal complications

 

Spelling and grammar is correct throughout   the presentation. APA format is consistently done and correct. All   information is referenced throughout the body of the presentation. Uses a   minimum of 3 credible references.

1

 

Discusses the significance of the blood   pressure. Outline what other assessments will be made by the nurse. 

What will be reported based on this finding?   

What condition are you assessing for? How   urgent is the reporting of this problem? 

2

 

Discusses the significance of the blood glucose   finding. Outline what other assessments will be made based on this finding.

What will be reported based on this finding?

What   condition are you assessing for?

How urgent is the reporting of this problem?   

2

 

Briefly discuss the common findings of   preeclampsia and nursing care and   management of this disorder. 

2

 

Briefly discuss the common findings of   gestational diabetes mellitus (GDM), and nursing care and management of this disorder.

2

 

Includes SBAR report for this patient.

1

 

 

While the implementation plan prepares students to apply their research to the problem or issue they have identified for their capstone change proposal project, the literature review enables students to map out and move into the active planning and development stages of the project.

A literature review analyzes how current research supports the PICOT, as well as identifies what is known and what is not known in the evidence. Students will use the information from the earlier PICOT Statement Paper and Literature Evaluation Table assignments to develop a 750-1,000 word review that includes the following sections:

1. Title page
2. Introduction section
3. A comparison of research questions
4. A comparison of sample populations
5. A comparison of the limitations of the study
6. A conclusion section, incorporating recommendations for further research

Prepare this assignment according to the guidelines found in the APA Style Guide, located in the Student Success Center. An abstract is not required.

This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.

You are required to submit this assignment to LopesWrite