Soap Note 2 Chronic Conditions

Soap Note 1 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 20% 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 20%. Copy paste from websites or textbooks will not be accepted or tolerated. Please see College Handbook with reference to Academic Misconduct Statement

Soap Note 2 Chronic Conditions

Soap Note 2 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)

Late Assignment Policy

Assignments turned in late will have 1 point taken off for every day assignment is late, after 7 days assignment will get grade of 0. No exceptions

 

Follow the MRU Soap Note Rubric as a guide:

Grading Rubric

Student______________________________________

This sheet is to help you understand what we are looking for, and what our margin remarks might be about on your write ups of patients. Since at all of the white-ups that you hand in are uniform, this represents what MUST be included in every write-up.

1)      Identifying Data (___5pts): The opening list of the note. It contains age, sex, race, marital status, etc. The patient complaint should be given in quotes. If the patient has more than one complaint, each complaint should be listed separately (1, 2, etc.) and each addressed in the subjective and under the appropriate number.

2)      Subjective Data (___30pts.): This is the historical part of the note. It contains the following:

a) Symptom analysis/HPI(Location, quality , quantity or severity, timing, setting, factors that make it better or worse, and associate manifestations.(10pts).

b) Review of systems of associated systems, reporting all pertinent positives and negatives (10pts).

c) Any PMH, family hx, social hx, allergies, medications related to the complaint/problem (10pts). If more than one chief complaint, each should be written u in this manner.

3)      Objective Data(__25pt.): Vital signs need to be present. Height and Weight should be included where appropriate.

a)      Appropriate systems are examined, listed in the note and consistent with those identified in 2b.(10pts).

b)      Pertinent positives and negatives must be documented for each relevant system.

c)        Any abnormalities must be fully described. Measure and record sizes of things (likes moles, scars). Avoid using “ok”, “clear”, “within normal limits”, positive/ negative, and normal/abnormal to describe things. (5pts).

4)      Assessment (___10pts.): Diagnoses should be clearly listed and worded appropriately.

5)      Plan (___15pts.): Be sure to include any teaching, health maintenance and counseling along with the pharmacological and non-pharmacological measures. If you have more than one diagnosis, it is helpful to have this section divided into separate numbered sections.

6)      Subjective/ Objective, Assessment and Management and Consistent (___10pts.): Does the note support the appropriate differential diagnosis process? Is there evidence that you know what systems and what symptoms go with which complaints? The assessment/diagnoses should be consistent with the subjective section and then the assessment and plan. The management should be consistent with the assessment/ diagnoses identified.

7)      Clarity of the Write-up(___5pts.): Is it literate, organized and complete?

Comments:

Total Score: ____________                                                          Instructor: __________________________________

 

Write a paper (1,250-1,500 words) describing the approach to care of cancer. In addition, include the following in your paper:

1. Describe the diagnosis and staging of cancer.
2. Describe at least three complications of cancer, the side effects of treatment, and methods to lessen physical and psychological effects.
3. Prepare this assignment according to the APA guidelines found in the APA Style Guide, located in the Student Success Center. An abstract is not required.

This assignment uses a grading rubric. Instructors will be using the
rubric to grade the assignment; therefore, students should review the rubric prior to beginning the assignment to become familiar with the assignment criteria and expectations for successful completion of the assignment.

You are required to submit this assignment to LopesWrite

Respond to at least two of your colleagues who selected a different factor than you, in one of the following ways:

Make a suggestion based on additional evidence drawn from readings or after synthesizing multiple postings.

Share insights based on your own experience and additional research.

                                                       Main post

Cardiovascular Alterations

It is essential to understand the typical structure and function of the cardiovascular system because alterations occur. Some changes can be pathologic and others not. Alhadheri (2005) states that 50 to 90 percent of children have a benign or functional murmur. In this post, I will explain how I would diagnose and prescribe treatment for the patient in the scenario, including how genetics impacts the diagnosis and treatment.

Diagnosis and Treatment

Making a proper diagnosis is necessary before allowing the teenager to engage in sports. The patient had no significant family history of cardiac death and an unremarkable medical history. The lack of patient medical history leads me to conclude that the problem is not acquired, but congenital. The physical assessment is not enough information to definitively determine the etiology of the murmur. It would be wise to run additional tests to rule out a pathological murmur. Appropriate tests include a chest x-ray, electrocardiogram, blood work, and echocardiogram (Alhadheri, 2005). The patient is asymptomatic, so I would order an echocardiogram looking for structural abnormalities. I suspect that the patient has mitral regurgitation based on the location and description of the sound in the scenario. Hammer and McPhee (2019) state that a murmur can be heard best at the apex of the heart with mitral regurgitation. Another possibility is coarctation of the aorta, but this is unlikely because the patient does not have diminished blood pressure nor pulses in the lower extremities. If mitral regurgitation is the case, the treatment may be surgical intervention. Either way, I would refer the patient for treatment to a pediatric cardiologist knowing that it is outside of my scope. A registered nurse practitioner is required to make a referral to a physician for a patient condition that is beyond their knowledge or experience (Arizona State Board of Nursing, 2018, p. 46).

Genetics

Genetics could impact the diagnosis. There is a high incidence of congenital heart defects with trisomies 13 and 18, Turner syndrome, and Down syndrome (Huether & McCance, 2017). The diagnosis could be a ventricular septal defect instead. However, I do not think the treatment would change if genetics were a factor. Usually, surgery is the intervention when the problem is pathological regardless of origin. 

References

Alhadheri, S. A. (2005). Children with Heart Murmurs…When to be Concerned?. Retrieved from https://apcardio.com/wp-content/themes/advancedpedia/pdf/Heart_Murmurs.pdf

Arizona State Board of Nursing. (2018, May 23). Rules of the State Board of Nursing. Retrieved June 24, 2019, from https://www.azbn.gov/media/2880/ruleseffectivemay232018.pdf

Hammer, G. D., & McPhee, S. J. (2019). Pathophysiology of disease: An introduction to clinical medicine (8th ed.). New York, NY: McGraw-Hill Education.

Huether, S. E., & McCance, K. L. (2017). Understanding pathophysiology (6th ed.). St. Louis, MO: Mosby.

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Mary Roach tackles the most pondered and least understood conundrums that have baffled humans for centuries. Based on the TED video by Mary Roach. Analyze and explain 10 things you did not know about orgasm. What did you learn? You must provide four paragraphs. Use the APA format. (Do not plagiarize)

 

  

Description

Part I: HIV/AIDS has affected millions of people in the United States and the world since the 1980s. On a global scale, large numbers of people with HIV/AIDS are not receiving the needed treatment. Congress created The Ryan White Care Act of 1990 to assist public hospitals struggling financially from caring for uninsured men and women living with HIV/AIDS. There were four Titles written into The Ryan White Care Act of 1990. In recent years the Titles have moved into five Parts, Part A-F focusing on a variety of topics.

In 2014, the Affordable Care Act gave insurance access to many of the uninsured population. Over the past few decades, countries like England and Canada have a lower percentage of HIV/AIDS cases. Is this due to their healthcare structure? In 4 pages, discuss the following.

a. Explain the purpose of each of the five Parts in The Ryan White Care Act.

b. Explain other viewpoints or opposing viewpoints of the Act.

c. Describe your stance on if there is a need for the Ryan White Care Act with the Affordable Care Act. Think about other countries. 

d. This portion of your assignment will require you to research and examine information from various sources. Use a minimum of three credible sources for your paper, with three being an academic source from the Rasmussen College Online Library (don’t forget to include in-text citations throughout your paper with paraphrasing or quoting)

e. Make sure to include your APA formatted reference page.

Part II: Based on your research you decide which one of the previous communication tools would be most effective to communicate your findings. Keep in mind the position and facility you selected and create a memo, a PowerPoint, detailed meeting agenda, or an information sheet. In the first paragraph, slide, or bullet please justify the reason you picked communication format. 

a. In the first paragraph, slide, or bullet please justify the reason you picked the particular communication format.

b. Use feedback from your instructor to guide you through the communication tool you decided to use.

c. Make sure to use audience specific language and tone.