In this assignment you will be required to write a Focused SOAP note, please do not submit a Complete SOAP note, you must learn to differentiate the two. If you do not have enough information to make a scholarly Focused note, you may make up information. For example, if the Family History is missing make up a history.

The Lab Assignment

Using evidence-based resources from your search, answer the following questions and support your answers using current evidence from the literature.

· Analyze the subjective portion of the note. List additional information that should be included in the documentation.

· Analyze the objective portion of the note. List additional information that should be included in the documentation.

· Is the assessment supported by the subjective and objective information? Why or why not?

· Would diagnostics 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 three different references from current evidence-based literature.

Week 10: Special Examinations—Breast, Genital,

Prostate, and Rectal

GENITALIA ASSESSMENT

Subjective:

• CC: “I have bumps on my bottom that I want to have checked out.”

• HPI: AB, a 21-year-old WF college student reports to your clinic with external

bumps on her genital area. She states the bumps are painless and feel rough.

She states she is sexually active and has had more than one partner during the

past year. Her initial sexual contact occurred at age 18. She reports no abnormal

vaginal discharge. She is unsure how long the bumps have been there but

noticed them about a week ago. Her last Pap smear exam was 3 years ago, and

no dysplasia was found; the exam results were normal. She reports one sexually

transmitted infection (chlamydia) about 2 years ago. She completed the

treatment for chlamydia as prescribed.

• PMH: Asthma

• Medications: Symbicort 160/4.5mcg

• Allergies: NKDA

• FH: No hx of breast or cervical cancer, Father hx HTN, Mother hx HTN, GERD

• Social: Denies tobacco use; occasional etoh, married, 3 children (1 girl, 2 boys)

Objective:

• VS: Temp 98.6; BP 120/86; RR 16; P 92; HT 5’10”; WT 169lbs

• Heart: RRR, no murmurs

• Lungs: CTA, chest wall symmetrical

• Genital: Normal female hair pattern distribution; no masses or swelling. Urethral

meatus intact without erythema or discharge. Perineum intact. Vaginal mucosa

pink and moist with rugae present, pos for firm, round, small, painless ulcer noted

on external labia

• Abd: soft, normoactive bowel sounds, neg rebound, neg murphy’s, negMcBurney

• Diagnostics: HSV specimen obtained

Assessment:

• Chancre

PLAN: 

 

We are still exploring section III which involves Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm

Our text readings will include concepts from:

Chapter 12: Helen Erickson, Evelyn Tomlin, and Mary Ann Swain’s Theory or Modeling and Role Modeling

Chapter 13: Barbara Dossey’s Theory of Integral Nursing

As healthcare professionals, we need to be aware of nursing theory, as you heard it many times that it applies to our practice as nurses. When you think about it, how many practicing nurses are aware of the nursing theories and how they use in their careers. If you have a chance this week, go and ask a colleague about what they know regarding nursing theorist and who may be their favorite theorist in the profession.

You will see an overlap in the three nursing theorist listed below (Erickson, Tomlin, and Swain).

As your read and explore the following website resources, think about how their works contribute to our current practices today in nursing.

We will investigate Modeling and Role Modeling in nursing; these concepts will build upon the four metaparadigms of nursing: Person, Environment, Health, and Nursing.

When using the modeling and role-modeling theory, the nurse attempts to understand the “client’s personal model of his or her world and to appreciate its value an significance for the client from the client’s perspective.” (Masters, 2015).  

Reference:

Masters, K. (2015). Nursing Theories: A Framework for Professional Practice. (2nd ed.). Burlington, Massachusetts. Jones & Bartlett Learning.

Who is Helen Erickson?

https://www.nursing-theory.org/theories-and-models/erickson-modeling-and-role-modeling-theory.php

Who is Evelyn Tomlin?

http://currentnursing.com/theory/modeling_and_role-modeling_theory.html

Who is Mary Ann Swain?

https://nursology.net/nurse-theorists-and-their-work/modeling-and-role-modeling/

Video: Modeling and Role Modeling

https://www.youtube.com/watch?v=MNRkJlzYp6I

Article: Modeling and Role Modeling

http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.841.9640&rep=rep1&type=pdf

Who is Barbara Dossey? What is her Theory of Integral Nursing?

An integral process is defined as a comprehensive way to organize multiple phenomenon of human experience and reality from four perspectives:

(1) the individual interior (personal/intentional);

(2) individual exterior (physiology/behavioral);

(3) collective interior (shared/cultural); and

(4) collective exterior (systems/structures) (Dossey, n.d.).

Consciousness & Holistic nursing – Barbara Dossey part 1 out of 2

Part One

https://www.youtube.com/watch?v=HD5pxzc9q0U&t=94s

Part Two

https://www.youtube.com/watch?v=mRAoD0-loWM

Website: Dossey Theory of Integral Nursing

http://www.dosseydossey.com/barbara/tin.html

PowerPoint: Barbara Dossey

http://www.dosseydossey.com/barbara/pdf/Dossey_Theory_of_Integral_Nursing_powerpoint.pdf