SOAP Note Assignment 2025

Instructions 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. Download the access codes . 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.

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This a case study discussed during the week. There are the questions and the answers. I NEED THE ANSWER TO THE LAST QUESTION. ALL THE QUESTIONS ARE RELATED TO THE SAME PATIENT What are the provisional and differential diagnoses? The most likely diagnosis is acute viral tonsillitis or group A beta-haemolytic streptococcal tonsillitis. The differential diagnoses are viral pharyngitis, laryngitis, parainfluenza, influenza, Epstein–Barr virus, or peritonsillar abscess. What factors increase the possibility that the infection is bacterial in origin? The majority of sore throats are viral in origin and will resolve spontaneously. Group A beta-haemolytic streptococcus is cultured in only 5–17% of adults with sore throat (Linder & Stafford 2001). Centor’s algorithm of clinical features (Centor et al. 1981) helps identify the significant features of streptococcal infection: 1. presence of tonsillar exudates, 2. tender anterior cervical lymphadenopathy, 3. the absence of cough 4. a history of fever. In this case, Ricardo had all four of these clinical signs. CBC that support the presence of an infectious process are the white blood cell count (WBC) and differential In non-localized infections of bacterial and viral origin, the total WBC count is elevated in non-immunosuppressed patients The next thing to look at is the differential which is the percentage of the various types of white blood cells present. u An increase in polymorphonuclear neutrophils, referred to as POLYS OR SEGS u Is seen in bacterial infections including endocarditis, septicemia and pneumonia u An immature form of this type of cell, referred to as a BAND, is often also seen, especially in acute infection u The appearance of these younger cells in the circulation is referred to as “SHIFT TO THE LEFT” How would you expect to find on this client Sedimentation rate Test and why? A high sed rate is a sign of a disease that causes acute inflammation in Ricardo’s body. Some conditions and medicines can affect the speed at which red blood cells fall, and they may affect this test results Because of poor response of this client to Antibiotics 3 days later pt still present 103 constant fever, headaches and vomiting without nausea. Pt was sent to ER and Lumbar Punction is needed. Mr. Ortego is alert and oriented x 3. BELOW IS THE QUESTION TO BE ANSWER What is your understanding as NP about Risk Communicating Challenges on this case? Mr. Ortego is alert and oriented x 3.

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