Please follow attachment and it will be on topic of bartholin cyst PRAC 6552: Advanced Nurse Practice in Reproductive Health Care

Please follow attachment and it will be on topic of bartholin cyst 

PRAC 6552:
Advanced Nurse Practice in Reproductive Health Care

Episodic/Focused SOAP Note Template

Patient Information:

Initials, Age, Sex, Race


S.

CC (chief complaint): This is a
brief statement identifying why the patient is here in the patient’s own words, for instance, “headache,”
not “bad headache for 3 days.”

HPI: This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. Use LOCATES Mnemonic to complete your HPI. You need to start
every HPI with age, race, and gender (e.g., 34-year-old African American female). You must include the seven attributes of each principal symptom in paragraph form, not a list. If the CC was “headache,” the LOCATES for the HPI might look like the following example:

Location: head

Onset: 3 days ago

Character: pounding, pressure around the eyes and temples

Associated signs and symptoms: nausea, vomiting, photophobia, phonophobia

Timing: after being on the computer all day at work

Exacerbating/relieving factors: light bothers eyes, Naproxen makes it tolerable but not completely better

Severity: 7/10 pain scale

Current Medications: Include dosage, frequency, length of time used, and reason for use. Also include over-the-counter (OTC) or homeopathic products.

Allergies:
Include medication, food, and environmental allergies separately. Provide a description of what the allergy is (e.g., angioedema, anaphylaxis). This will help determine a true reaction versus intolerance.

PMHx: Include immunization status (note date of
last tetanus for all adults), past major illnesses, and surgeries. Depending on the CC, more info is sometimes needed.

Soc & Substance Hx: Include occupation and major hobbies, family status, vaping, tobacco and alcohol use (previous and current use, how many times a day, how many years), and any other pertinent data. Always add some health promotion questions here, such as whether they use seat belts all the time or whether they have working smoke detectors in the house, the condition of the living environment, text/cell phone use while driving, and support systems available.

Fam Hx: Illnesses with possible genetic predisposition, contagious illnesses, or chronic illnesses. The reason for death of any deceased first-degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent.

Surgical Hx:
Prior surgical procedures.

Mental Hx:
Diagnosis and treatment. Current concerns: (Anxiety and/or depression). History of self-harm practices and/or suicidal or homicidal ideation.

Violence Hx:
Concern or issues about safety (personal, home, community, sexual—current and historical).

Reproductive Hx: Menstrual history (date of last menstrual period [LMP]), pregnant (gravida and Parity), nursing/lactating (yes or no), contraceptive use (method used), Sexually active? types of intercourse (oral, anal, vaginal, other), gender sexual preference, and any sexual concerns.

ROS: This covers all body systems that may help you include or rule out a differential diagnosis. You should list each system as follows:
General:
Head:
EENT: and so forth. You should list these in bullet format and document the systems in order from head to toe.

Example of Complete ROS:

GENERAL: No weight loss, fever, chills, weakness, or fatigue.

HEENT: Eyes: No visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.

SKIN: No rash or itching. Breast-lumps, pain, discharge?

CARDIOVASCULAR: No chest pain, chest pressure, or chest discomfort. No palpitations or edema.

RESPIRATORY: No shortness of breath, cough, or sputum.

GASTROINTESTINAL: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood.

NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control.

MUSCULOSKELETAL: No muscle pain, back pain, joint pain, or stiffness.

HEMATOLOGIC: No anemia, bleeding, or bruising.

LYMPHATICS: No enlarged nodes. No history of splenectomy.

PSYCHIATRIC: No history of depression or anxiety.

ENDOCRINOLOGIC: No reports of sweating or cold or heat intolerance. No polyuria or polydipsia.

GENITOURINARY: Burning on urination. Breast-lumps, pain, discharge? No reports of vaginal discharge, pain?

ALLERGIES: No history of asthma, hives, eczema, or rhinitis.


O.

Physical exam: From head to toe, include
what you see, hear, and feel when conducting your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and history.
Do not use “WNL” or “normal.” You must describe what you see. Always document in head-to-toe format (i.e., General: Head: EENT:).

Diagnostic results: Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines).


A

.

Primary and Differential Diagnoses (list a minimum of 3 differential diagnoses). Your
primary or presumptive diagnosis should be at the top of the list. For each diagnosis, provide supportive documentation with evidence-based guidelines.


P.

Includes documentation of diagnostic studies that will be obtained, referrals to other health care providers, therapeutic interventions, education, disposition of the patient, and any planned follow-up visits. Each diagnosis or condition documented in the assessment should be addressed in the plan. The details of the plan should follow an orderly manner.
Also included in this section is the reflection. The student should reflect on this case and discuss whether or not they agree with their preceptor’s treatment of the patient and why or why not. What did they learn from this case? What would they do differently?

Also include in your reflection a discussion related to health promotion and disease prevention, taking into consideration patient factors (e.g., age, ethnic group), PMH, and other risk factors (e.g., socioeconomic, cultural background).

References

You are required to include at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines that relate to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 7th edition formatting.

© 2023 Walden University, LLC

Share This Post

Email
WhatsApp
Facebook
Twitter
LinkedIn
Pinterest
Reddit

Order a Similar Paper and get 15% Discount on your First Order

Related Questions

Patricia Martin Giraldino Florida National University Decision Making 10/29/2024Consider how clinical judgment, critical thinking, and decision

Patricia Martin Giraldino Florida National University Decision Making 10/29/2024 Consider how clinical judgment, critical thinking, and decision-making are similar and different, and describe these in your own words. Clinical reasoning, thinking, and decision-making are closely intertwined processes but are not completely synonymous in function and usage. Clinical judgment refers to

pls see attachment for further instructions  Skin, Eye, & Ear Disorders

pls see attachment for further instructions  Skin, Eye, & Ear Disorders Case 3 Chief Complaint (CC)  A 11-year-old female patient complains of red left eye and edematous eyelids. Her mother states the child complains of “sand in my left eye.” Subjective Patient noticed redness three days ago. Denies having any

Module 3 Discussion     Skin, Eye, & Ear DisordersFor this

Module 3 Discussion      Skin, Eye, & Ear Disorders For this Discussion, you will take on the role of a clinician who is building a health history for one of the following cases. Your instructor will assign you your case number. Case 1 Chief Complaint (CC)  A 57-year-old man

Module 3 Discussion    ACA and Health-Care Outcomes & Costs

Module 3 Discussion     ACA and Health-Care Outcomes & Costs What components of the ACA do you think will have a positive effect on improving health care outcomes and decreasing costs?    Submission Instructions: · Your initial post should be at least 500 words, formatted and cited in current APA

Using the following source;  Health Care Access and Quality – Healthy People 2030 | odphp.health.gov , make an initial post following the rubric.    This

Using the following source;  Health Care Access and Quality – Healthy People 2030 | odphp.health.gov , make an initial post following the rubric.    This week, you will consider assessment questions and appropriate interventions related to social determinants of health. Healthy physical, social, and economic environments strengthen the potential to achieve

Select TWO of the following questions to answer. Restate the questions you selected in the discussion forum and answer each separately. Question:

Select TWO of the following questions to answer. Restate the questions you selected in the discussion forum and answer each separately. Question: Leininger’s Culture Care Theory presents three culture care modes of decisions or actions. Describe what is meant by culture care preservation and/or maintenance; culture care accommodation and/or negotiation,