Part I : 

a. Soap Note Ankylosing Spondylitis

b. add questions from your case study 

Part II: Ankylosing Spondylitis

a. Pathophysiology

b. Clinical Presentation

c. Physical Examination

d. Diagnostic Testing 

e. Differential Diagnosis

f. Management

g. Education and Health Promotion 

Power point

< 20 % plagiarism

5 References

Sample Regular Soap Note Template

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 200lb, 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(ICD10E05.90)

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 monitoringat 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).

CodinaLeik, M. T. (2014). Family Nurse Practitioner Certification Intensive Review (2nd ed.). ISBN 978-0-8261-3424-0

 

200 words for each respond

1.

 

According to the Centers for Disease Control and Prevention (CDC, 2018), a community health assessment is a localized study of a specific group whether it is local, statewide, tribal, or territorial. This research helps organizations and the government identify specific health needs and issues through the gathering of data. Community health assessments are needed to help improve the overall health of the population. It provides agencies with facts and numbers that would create a better and clearer understanding of the areas they want to serve.

Benefits

            There are many tools available to help facilitate this endeavor. The majority of the models use similar processes. Their goal is to determine the community’s strengths, weaknesses, needs, and assets. Some of the benefits of choosing one model toolkit versus another depends on the number of steps and the depth of the research that the organization or group wants to perform. In addition, it seems that not all the toolkits are designed to assess the same type of data, and their focus appears to be different as well. Some are specific to hospitals, while others are more engaged on public health. Using a specific model to assess the community will ensure that the data collected would be used and analyzed to help improve, engage, and prioritize issues that affect the public. 

Agencies and Time Line

            When doing a community health assessment, agencies need to be involved in order to have a more comprehensive understanding of the surroundings and the people that live in the community. Agencies such as schools, healthcare organizations, private and governmental institutions, local workforce agencies, and churches are some of the key assets when conducting a community health assessment. All of their voices, input, and expertise are valuable resources. They could serve as tools that community health nurses may use to implement changes in their areas and help make a difference in the population. According to Catholic Health Association of the United States (CHAUS, 2015), hospitals should expect to spend approximately six to 18 months planning and conducting their community health assessment. This number will vary according to the size of the hospital, the size of the community, and the number of organizations involved in the process. In addition, the availability of financial resources will have an influence on the duration of the process (CHAUS, 2015).

The Role of the Public Health Nurse

            The role of the public health nurse in implementing the community health assessment model is essential in this process. The nurse can serve as a guide to educate, advocate, assess and evaluate individuals in the community. They have in-depth knowledge about the different determinants of health that affect the community as well as thorough understanding of the many aspects that influence the needs of the population. They also play a vital role in collaborating with agencies to help collect data and implement measures to achieve improvements in the health and social conditions of the most vulnerable populations.

References

Catholic Health Association of the United States. (2015). Assessing and addressing community

health needs. Retrieved from https://www.chausa.org/docs/default-source/community-benefit/2015-cbassesmentguide.pdf?sfvrsn=2

Centers for Disease Control and Prevention. (2018, July 24). Community health assessment and

health improvement plans. Retrieved from https://www.cdc.gov/publichealthgateway/cha/plan.html#three

2. 

Prior to this week, I was unaware of what a community assessment consisted of. I learned that most of these assessment tools consist of phases an steps to follow. This phases and steps include organizing a plan, engaging in the community, and developing a goal to achieve. You must then do the community health assessment, prioritize the information you have assessed, and develop the plan to achieve your goal. Once all of this has been established, you can implement this into the community and evaluate the process. On the CDC website, I chose the model Mobilizing for Action through Planning and Partnerships (MAPP). A brief description from the CDC website included was a framework for a community improvement planning and putting a strong emphasis on the engagement and collaboration in the community on a local level (CDC-Assessment, 2015). This specific community assessment plan to help improve community health. Through this plan, it allows communities to apply critical thinking to prioritize issues in public health and to help identify the resources needed to address the issues. This ultimately improves efficiency and effectiveness throughout the community and improves the overall outcome of the community. There are six phases to go through with this community assessment model. Stage 1 of this model includes how to get organized develop a partnership. Stage 2 is visioning which allows us to share community vision and goals to accomplish. Phase 3 includes the four assessments, we are able to analyze and collect data during this phase. Stage 4 helps you identify the issues within the community so you can base your plan upon the issues. Stage 5 helps you determine a plan and goals to reach while stage 6 is when you put your plan into action within the community  (MAPP, n.d). I feel that the community health nurse has a lot of research to do based on this community assessment. I think it would be best to team up with leaders through out the local community such as the health department and maybe even emergency services since they have so many statistics on our population for our community. I think a reasonable time frame would include four to eight months for a community assessment.

CDC – Assessment – Community Health Assessment – STLT Gateway. (2015, November 9). Retrieved from https://www.cdc.gov/publichealthgateway/cha/assessment.html.

Mobilizing for Action through Planning and Partnerships (MAPP). (n.d.). Retrieved from https://www.naccho.org/programs/public-health-infrastructure/performance-improvement/community-health-assessment/mapp.

The interpretation of research in health care is essential to decision making. By understanding research, health care providers can identify risk factors, trends, outcomes for treatment, health care costs and best practices. To be effective in evaluating and interpreting research, the reader must first understand how to interpret the findings. You will practice article analysis in Topics 2, 3, and 5.

For this assignment:

Search the GCU Library and find three different health care articles that use quantitative research. Do not use articles that appear in the Topic Materials or textbook. Complete an article analysis for each using the “Article Analysis 1” template.

Refer to the “Patient Preference and Satisfaction in Hospital-at-Home and Usual Hospital Care for COPD Exacerbations: Results of a Randomised Controlled Trial,” in conjunction with the “Article Analysis Example 1,” for an example of an article analysis.

While APA style is not required for the body of this assignment, solid academic writing is expected, and documentation of sources should be presented using APA formatting guidelines, which can be found in the APA Style Guide, located in the Student Success Center.

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. Refer to the LopesWrite Technical Support articles for assistance.

AttachmentsHLT-362V-RS2-ArticleAnalysisExample-1.docx
HLT-362V-RS2-ArticleAnalysis-1-Template.docx

 

You are now a public safety manager.  You and your team have been working on a new catastrophe (your topic), and you have been tasked with presenting your proposed project for approval and funding to the County Board of Commissioners, Sheriff, Chief of Police, Fire Chief, Emergency Operations Director, or State Commissioner for approval and funding in this scenario. 

Briefly, and in your own words, explain to the class what you are proposing, its intended propose, and how the organization and community will benefit from this proposed plan. This is a brief summary whereas you need to sell this plan to your audience in two paragraphs or less. 

 

Chapter 41

A patient is admitted with renal calculi.

a.            What symptoms will the patient manifest if he is experiencing renal colic?

b.            How will the nurse best manage the renal colic?

c.             The nurse is straining the urine for presence of stones that the patient may have passed. What is the importance of this nursing action?