Soap Hypertension And Depressive Disorder

SOAP NOTE SAMPLE FORMAT FOR MRC

Name: LP

Date:

Time: 1315

Age: 30

Sex: F

SUBJECTIVE

CC:

“I am having vaginal itching and pain in my lower abdomen.”

HPI:

Pt is a 30y/o AA female, who is a new patient that has recently moved to Miami. She seeks treatment today after unsuccessful self-treatment of vaginal itching, burning upon urination, and lower abdominal pain. She is concerned for the presence of a vaginal or bladder infection, or an STD. Pt denies fever. She reports the itching and burning with urination has been present for 3 weeks, and the abdominal pain has been intermittent since months ago. Pt has tried OTC products for the itching, including Monistat and Vagisil. She denies any other urinary symptoms, including urgency or frequency. She describes the abdominal pain as either sharp or dull. The pain level goes as high as 8 out of 10 at times. 200mg of PO Advil PRN reduces the pain to a 7/10. Pt denies any aggravating factors for the pain. Pt reports that she did start her menstrual cycle this morning, but denies any other discharge other that light bleeding beginning today. Pt denies douching or the use of any vaginal irritants. She reports that she is in a stable sexual relationship, and denies any new sexual partners in the last 90 days. She denies any recent or historic known exposure to STDs. She reports the use of condoms with every coital experience, as well as this being her only form of contraceptive. She reports normal monthly menstrual cycles that last 3-4 days. She reports dysmenorrhea, which she also takes Advil for. She reports her last PAP smear was in 7/2016, was normal, and reports never having an abnormal PAP smear result. Pt denies any hx of pregnancies. Other medical hx includes GERD. She reports that she has an Rx for Protonix, but she does not take it every day. Her family hx includes the presence of DM and HTN.

Current Medications:

Protonix 40mg PO Daily for GERD

MTV OTC PO Daily

Advil 200mg OTC PO PRN for pain

PMHx:

Allergies:

NKA & NKDA

Medication Intolerances:

Denies

Chronic Illnesses/Major traumas

GERD

Hospitalizations/Surgeries

Denies

Family History

Father- DM & HTN; Mother- HTN; Older sister- DM & HTN; Maternal and paternal grandparents without known medical issues; 1 brother and 3 other sisters without known medical issues; No children.

Social History

Lives alone. Currently in a stable sexual relationship with one man. Works for DEFACS. Reports occasional alcohol use, but denies tobacco or illicit drug use.

ROS

General

Denies weight change, fatigue, fever, night sweats

Cardiovascular

Denies chest pain and edema. Reports rare palpitations that are relieved by drinking water

Skin

Denies any wounds, rashes, bruising, bleeding or skin discolorations, any changes in lesions

Respiratory

Denies cough. Reports dyspnea that accompanies the rare palpitations and is also relieved by drinking water

Eyes

Denies corrective lenses, blurring, visual changes of any kind

Gastrointestinal

Abdominal pain (see HPI) and Hx of GERD. Denies N/V/D, constipation, appetite changes

Ears

Denies Ear pain, hearing loss, ringing in ears

Genitourinary/Gynecological

Reports burning with urination, but denies frequency or urgency. Contraceptive and STD prevention includes condoms with every coital event. Current stable sexual relationship with one man. Denies known historic or recent STD exposure. Last PAP was 7/2016 and normal. Regular monthly menstrual cycle lasting 3-4 days.

Nose/Mouth/Throat

Denies sinus problems, dysphagia, nose bleeds or discharge

Musculoskeletal

Denies back pain, joint swelling, stiffness or pain

Breast

Denies SBE

Neurological

Denies syncope, seizures, paralysis, weakness

Heme/Lymph/Endo

Denies bruising, night sweats, swollen glands

Psychiatric

Denies depression, anxiety, sleeping difficulties

OBJECTIVE

Weight 140lb

Temp -97.7

BP 123/82

Height 5’4”

Pulse 74

Respiration 18

General Appearance

Healthy appearing adult female in no acute distress. Alert and oriented; answers questions appropriately.

Skin

Skin is normal color for ethnicity, warm, dry, clean and intact. No rashes or lesions noted.

HEENT

Head is norm cephalic, hair evenly distributed. Neck: Supple. Full ROM. Teeth are in good repair.

Cardiovascular

S1, S2 with regular rate and rhythm. No extra heart sounds.

Respiratory

Symmetric chest walls. Respirations regular and easy; lungs clear to auscultation bilaterally.

Gastrointestinal

Abdomen flat; BS active in all 4 quadrants. Abdomen soft, suprapubic tender. No hepatosplenomegaly.

Genitourinary

Suprapubic tenderness noted. Skin color normal for ethnicity. Irritation noted at labia majora, minora, and perineum. No ulcerated lesions noted. Lymph nodes not palpable. Vagina pink and moist without lesions. Discharge minimal, thick, dark red, no odor. Cervix pink without lesions. No CMT. Uterus normal size, shape, and consistency.

Musculoskeletal

Full ROM seen in all 4 extremities as patient moved about the exam room.

Neurological

Speech clear. Good tone. Posture erect. Balance stable; gait normal.

Psychiatric

Alert and oriented. Dressed in clean clothes. Maintains eye contact. Answers questions appropriately.

Lab Tests

Urinalysis – blood noted (pt. on menstrual period), but results negative for infection

Urine culture testing unavailable

Wet prep – inconclusive

STD testing pending for gonorrhea, chlamydia, syphilis, HIV, HSV 1 & 2, Hep B & C

Special Tests- No ordered at this time.

Diagnosis

Differential Diagnoses

1-Bacterial Vaginosis (N76.0)

2- Malignant neoplasm of female genital organ, unspecified. (C57.9)

3-Gonococcal infection, unspecified. (A54.9)

Diagnosis

o Urinary tract infection, site not specified. (N39.0) Candidiasis of vulva and vagina. (B37.3) secondary to presenting symptoms (Colgan & Williams, 2011) & (Hainer & Gibson, 2011).

Plan/Therapeutics

Plan:

Medication –

§ Terconazole cream 1 vaginal application QHS for 7 days for Vulvovaginal Candidiasis;

§ Sulfamethoxazole/TMP DS 1 tablet PO twice daily for 3 days for UTI (Woo & Wynne, 2012)

Education –

§ Medications prescribed.

§ UTI and Candidiasis symptoms, causes, risks, treatment, prevention. Reasons to seek emergent care, including N/V, fever, or back pain.

§ STD risks and preventions.

§ Ulcer prevention, including taking Protonix as prescribed, not exceeding the recommended dose limit of NSAIDs, and not taking NSAIDs on an empty stomach.

Follow-up –

§ Pt will be contacted with results of STD studies.

§ Return to clinic when finished the period for perform pap-smear or if symptoms do not resolve with prescribed TX.

GENOGRAM FOR CLIENT

Prepare A Genogram For The Client You Selected. The Genogram Should Extend Back By At Least Three Generations (Great Grandparents, Grandparents, And Parents)

I will provide a client without violating HIPPA these are the areas need to be addressed in the genogram

Demographic information

Presenting problem

History or present illness

Past psychiatric history

Medical history

Substance use history

Developmental history

Family psychiatric history

Psychosocial history

History of abuse/trauma

Review of systems

Physical assessment

Mental status exam

Differential diagnosis

Case formulation

Treatment plan

Pain Today (0-10): Pain is described as 1 out of 10. Allergies: NKDA SLEEP ISSUES: Hours of sleep per night: 6-7 Snores: No Sleep latency: 0-15 min Daytime Somnolence: No Substance History: Caffeine Use: No Cups/Date Equivalent: Tobacco/e-cigs: none Packs/Date Equivalent: Illicit drug use: denied DEVELOPMENTAL/SOCIAL HISTORY: Patient reports that he grew up in Mississippi. His father died in a motor vehicle accident when he was several months old. Raised by his mother and stepfather. Denies any abuse history. Never married. Has a bachelor’s of arts in communication from Grambling UNIV. reports that he worked at Lowe’s during college and thereafter. Is an AGR Soldier within the United States Army reserves in Mississippi from 2012-2018. States that his religion and spiritual values preference being Christian. Patient was primarily raised by Biological parents and that childhood was generally Good. Patient denies ever being physically, sexually or emotionally abused. Highest level of education achieved is: 4-year college degree or equivalent. Patient is currently single and currently lives with Other. Housing is currently Off-Post. Patient reports religion, faith or spirituality DO play an important role in life. Social support reported as satisfactory. Patient reports the following history of legal issues: None of the above. PAST FAMILY/MEDICAL HISTORY: Family Medical Illnesses: None Family Behavioral Health Illnesses: None Family Substance Use History: None OBJECTIVE MSE Orientation: ☐None ☒Place ☒Object ☒Person ☒Time Attention: ☒Normal ☐Distracted ☒Other: Maintained focus and attention throughout the session. Appearance: ☒Neat ☐Disheveled ☐Inappropriate ☐Bizarre ☒Other: dressed in civilian attire. Behavior: ☒Cooperative ☐Guarded ☐Withdrawn ☐Agitated ☐Stereotyped ☐Aggressive ☒Other: calm Eye Contact: ☒Normal ☐Intense ☐Limited ☒Other: maintained appropriate eye contact during the session. Psychomotor: ☒Normal ☐Restless ☐Tics ☐Slowed ☐Other Speech: ☒Normal rate, volume, and rhythm ☐Tangential ☐Pressured ☐Impoverished ☐Other Mood: “I feel good overall.” Affect: ☒Congruent with mood ☒Euthymic ☐Anxious ☐Angry ☐Depressed ☐Euphoric ☐Irritable ☐Constricted ☐Flat ☐Labile ☐Other Thought Process: ☒WNL ☐Circumstantial ☐Tangential ☐Loose Associations ☐Disorganized ☐Other Thought Content: ☒WNL ☐SI ☐HI ☒ potentially paranoid ☐A/V hallucinations ☐Delusional ☒Other: Denies SI/HI plan or intent Memory Impairment: ☒WNL ☐Short-Term ☐Long-Term ☐Other Insight: ☐Good ☒Fair ☐Poor Comments: Judgment: ☐Good ☒Fair ☐Poor Comments: BHDP: Behavioral Health Vitals (patient reported): Overall health reported as: Good Pain Level (0-10): 0 Currently treated: N/A Suicidal Ideation Risk – C-SSRS-S score: 0 Past/Prep Behavior last 3 months: N/A # past attempts as of 12/07/2016: 2 Most recent Suicidal Ideation: N/A Suicidal Ideation Duration: N/A Suicidal Ideation Frequency: N/A Protective Elements Stopping Suicidal Actions: Faith/Religion, Family, Hope for future, Friends, Other Harm Others Risk over next week as of 12/18/2018 – None Active Plan: N/A Patient with access to weapons: No Recent Outcome Measures (last 30 days) BASIS24 – Score: 0.56 – Subclinical to low level of general distress reported (12/18/2018) PHQ9 – Score: 4 – Depressive syndrome unlikely (12/18/2018) GAD7 – Score: 3 – Anxiety syndrome unlikely (12/18/2018) PCL-5 – Score: 3 – None-Low PTSD symptoms reported (12/18/2018) PCL-C: N/A AUDIT: N/A CSI – Score: 8 – Possible relationship distress reported. Evaluation indicated. (11/30/2018) ISI – Score: 9 – Subthreshold insomnia (12/18/2018) BAM: N/A LABORATORY RESULTS: Reviewed laboratory results ASSESSMENT Patient Strengths: ☐ None reported ☐ motivated ☐ insightful ☐ committed ☐ Tx compliant ☒ family support ☐ social support ☐desires change ☐ previous positive BH experience ☐ desire to address longstanding issues ☒ good expressive language ☐ good ego strength ☐ Other: Patient Barriers: ☐ None reported ☐ unmotivated ☐ limited insight ☒ uncommitted ☐ Tx non-compliant ☐ limited family support: ☐resistant ☐co-morbid Dx ☐ previous negative BH experience ☒ limited social support ☐cognitive impairment/TBI ☐low ego strength ☒ Other: Not resistant but questions the validity of his behavioral healthcare SAFETY RISK ASSESSMENT ☐YES ☒NO History of Suicidal Ideation: ☐YES ☒NO History of Suicidal Planning: ☐YES ☒NO History of Suicidal Gestures: ☐YES ☒NO History of Suicidal Attempts: ☐YES ☒NO Close friends/family who have attempted/completed suicide: ☐YES ☒NO History of intentionally harming others or destroying property: ☐YES ☒NO Current intentions to engage in above behaviors: ☐YES ☒NO History of impulsive-taking: Risk Factors: ☐None reported ☒Male ☐Impulsive ☒Weapons access ☐Legal Stressors ☐Financial Stressors ☒Occupational conflict ☐Chronic medical problems ☐Substance abuse: ☐Abuse victim: ☐History of suicidal gestures ☐History of family/friend suicide ☐Relationship problems ☐OTHER: insomnia Protective Factors: ☐None reported ☐Married ☐Children ☒Positive religious coping ☒Future orientation ☒Healthy coping skills ☐Active treatment participation ☒Supportive spouse ☐Supportive family ☐Social support ☒PT wants to continue treatment ☐OTHER: This provider considered the above risk/protective factors and has determined the following risk level: RISK: Harm to Self – ☒Not Elevated ☐Low ☐Intermediate ☐High Harm to Others – ☒Not Elevated ☐Low ☐Intermediate ☐High SAFETY:☐YES ☒NO Imminent threat to self. ☐YES ☒NO Imminent threat to others. ☐YES ☒NO Imminent threat of harm from other individuals. ☒YES ☐NO Patient is fully able to make informed medical decisions and manage affairs. ☒YES ☐NO Patient is unlikely to withhold information about SI/HI ideation or intent. ☒YES ☐NO Patient is considered to be a reliable source of information. DIAGNOSTIC FORMULATION: This is a 35-year-old male who was deployed to the Middle East as an individual unit augmentee. He reports that he became an conflict with his leadership over mishandling funds, and other ethical related issues. The unit is making the claim that the patient is misperceiving these incidences, based off of the provider assessment in-theater; paranoia over this situation was identified. DSM Diagnosis(es) Code: Other occupational structure stressors R/O: Delusional Disorder, psychosis Estimated Treatment Prognosis: Good . PLAN Treatment Summary: 1) Patient was provided psychoeducation, assessment of current functioning, risk/safety assessment, development of rapport, development of treatment goals, empathic listening and directed questioning techniques to elicit information and provided supportive environment to facilitate patient insight. Patient was provided active listening, strategic reflection, encouragement and validation. Other therapies discussed include: 1. Diaphragmatic Breathing 2. Progressive Muscle Relaxation 3. Safe Place Imagery 4. Mindful breathing 5. Problem solving techniques 6. Sleep Hygiene 7. Discussed, Virtual Hope box, Tactical Breather, Moving forward and Mindfulness coach apps available on smart phone. 2) Discussed open-access clinic available at BH clinic. Pt agree if symptoms worsen or if new behavioral concerns arise, Pt to call, RTC, or if after duty hours, go to ED and/or call emergency line. Limits to confidentiality were discussed with the patient as appropriate. 3) Attending behavioral health group for deployed service members on Monday, Tuesday, Thursday and/or Friday from 1430-1600. Medications: None Risk/Suicide Management Plan: ☒YES ☐N/A The patient will follow-up in therapy to address treatment goals. ☒YES ☐N/A The patient has demonstrated the ability to and has agreed to make use of a crisis response plan. ☐YES ☒N/A The patient was added to the High Interest Program to track continuity of care. ☐YES ☒N/A Persons notified: ☐YES ☒N/A Emergency Contacts: ☒YES ☐N/A Emergency Contacts and Crisis Response Plan: Call friends, family members, or a trusted chaplain. Contact Military One Source at http://www.militaryonesource.mil/ or call 00-800-3429-6477. Call Wounded Soldier and Family Hotline at OCONUS DSN 312-421-3700. Access www.realwarriors.net/livechat for online chat support. After duty hours, call 112, call MPs, First Sergeant or primary supervisor if feeling suicidal. During duty hours, walk in to Behavioral Health Clinic. Go to the Emergency Room at Landstuhl Regional Medical Center. They will call the on-call Behavioral Health Provider. ☐YES ☒N/A Safety plan worksheet uploaded into HAIMS.

Evidence-Based Practice Proposal Project Development And Implementation Plan 2

Please specifically identify the financial, quality and clinical aspects for developing

your EBP project with emphasis on the direct and indirect impact of each aspects.

This is a follow up question based on the answer provided for this post…

https://www.homeworkmarket.com/questions/topic-6-evidence-based-practice-proposal-project-development-and-implementation-plan-2-dq2

Nursing Role

There is a wide variety of perspectives and frameworks from which to practice nursing. After reading the various framework and theories presented, which most closely matches your beliefs? Please explain why?

Professional Communication (Articulation) – The submission on ethical dilemmas

Professional Communication (Articulation) – The submission on ethical dilemmas and the Mr. Newcomb scenario is informative and generally comprehensive. Recurring parts of speech, sentence fluency, and word choice errors are present and impact the clarity of the response. These errors include missing words, unclear phrasing, inaccurate word choices, incorrect prepositions, and incorrect verb forms.

Content – The submission thoughtfully examines the task scenario of a hypothetical patient called Mr. Newcomb, who is requesting to visit with his mistress, where the nurse would respond by explaining that they cannot fulfill his request of deceiving Mrs. Newcomb, as this is morally and ethically wrong. The paper practically describes how the nurse would apply beneficence, non-maleficence, justice, and autonomy, to the task scenario, by showing empathy, refraining from acts that would cause harm like lying, maintaining a standard of fairness for all patients, and recognizing that Mr. Newcomb has a right to make his own choices. The submission logically discusses multiple strategies to promote self-care for the professional caregiver, which includes allowing oneself to cry and feel “raw,” exercising to find relaxation, and watching a movie with one’s significant other and their dogs. The omission of various components (author, title, date, and source location) for two bibliography entries negatively impacts the retrievability of the sources, requiring further review and corrections.

Evaluator Attached Files

276 RGP Task 2_Sept 14.pdf

A1. RESPONSE TO SCENARIO

Competent

A2. APPLICATION OF PATIENT PRINCIPLES

Competent

A3. PERSONAL BELIEFS AND VALUES

Competent

A4. PROMOTING SELF-CARE STRATEGIES

Competent

B. SOURCES

Approaching Competence

Approaching CompetenceThe submission includes in-text citations for sources that are quoted, paraphrased, or summarized, and a reference list; however, the citations and/or reference list is incomplete or inaccurate.

EVALUATOR COMMENTS: ATTEMPT 1

Summarized and Paraphrased information related to the discussions of ethical principles is acknowledged with in-text citations and a reference-list. The omission of various components (author, title, date, and source location) for two bibliography entries impacts the retrievability of the sources. Inclusion of this key information is needed to facilitate retrieval of the sources. For specific instruction about in-text and reference-list citations, please click on the link located in the rubric item ‘Sources.’ Please contact the WGU Writing Center if further assistance is needed.

C. PROFESSIONAL COMMUNICATION

Approaching Competence

Approaching CompetenceContent is poorly organized, is difficult to follow, or contains errors in mechanics, usage, or grammar that cause confusion. Terminology is misused or ineffective.

EVALUATOR COMMENTS: ATTEMPT 1

This aspect has been evaluated by a Professional Communication evaluator, and a comprehensive summary of the evaluation outcome can be found in the overall comment. The evaluation includes a markup document featuring examples of the most pervasive errors relating to this rubric aspect. Please review the overall comment and the attached markup for details regarding the writing errors identified.

More information about competency standards required for this rubric aspect can be found in the WGU Knowledge Center: FAQs about Professional Communication. Students are also encouraged to utilize the WGU Writing Center resources for assistance with review and revisio

Instructions

SCENARIO

You have been working as a nurse in the adult oncology unit for the past year. You have developed a close relationship with many of your patients, but Mr. Newcomb has a special place in your heart. He has been diagnosed with stage 4 pancreatic cancer and has undergone aggressive chemotherapy. Each day his wife has come to the unit to be with her husband. They have been married for over 40 years and share a deep love. Mr. and Mrs. Newcomb have made the decision to no longer continue with treatment and have decided that hospice care is needed. Over the past few days, you have watched Mr. Newcomb’s health decline, and you can tell from your experience that he does not have much time left to live. Mr. Newcomb has been very open about discussing his death, and you have had the opportunity to learn about his life and the legacy he will leave behind. While you are completing your rounds, you stop in Mr. Newcomb’s room to see how he is doing. You ask, “Is there anything else I can do for you?” Mr. Newcomb has rarely asked for anything, but today he has one request. Mr. Newcomb states, “Before I die, I would like to see my mistress one more time. Mrs. Newcomb is always here. Do you think you could tell her that I will be busy for a few hours tomorrow so I can make arrangements to see my mistress one more time?” Reflect on the following questions before you begin working on this task:

• What would you do in this scenario?

• How can your knowledge of ethical principles be utilized to determine your response to Mr. Newcomb?

• How would this affect you as a nurse and direct provider of care for Mr. Newcomb?

REQUIREMENTS

A. Summarize how the principles of beneficence, non-maleficence, autonomy, and justice apply to the scenario by doing the following:

1. Describe how you would respond to Mr. Newcomb’s request.

2. Evaluate how you applied the principles of beneficence, non-maleficence, autonomy, and justice to the scenario.

3. Examine how personal beliefs and values influenced your response to the scenario.

4. Describe three strategies to promote self-care.

B. Acknowledge sources, using in-text citations and references, for content that is quoted, paraphrased, or summarized.

C. Demonstrate professional communication in the content and presentation of your submission.

Are Cell Phones Dangerous?

Write a 5 paragraph essay with the following components:

Introduction:

a. Hook/Grabber:

question

statement

data/fact

Background info on the topic

Thesis Statement: inform the reader about what your essay will be about; last sentence of the intro para.

Body Paragraphs:

2 paragraphs containing the pros of the use of cellphones

1 paragraph containing the cons of the use of cellphones

Building Main Points:

Organize with the use of topic sentences that illustrate the main idea of each paragraph.Offering a brief explanation of the history or recent developments of topic within the early body paragraphs can help the audience to become familiarized with your topic and the complexity of the issue.

Paragraphs may be ordered in several ways, depending upon the topic and purpose of your argument:•General to specific information• Most important point to least important point . Weakest claim to strongest claim

Countering the Opposition:

Addressing the claims of the opposition is an important component in building a convincing argument.

It demonstrates your credibility as a writer –

you have researched multiple sides of the argument and have come to an informed decision.

It shows you have considered other points of view – that other points of view are valid and reasonable

Effective Counter Arguments:

Consider your audience when you address the counterargument.

Conceding to some of your opposition’s concerns can demonstrate respect for their opinions.

Remain tactful yet firm: Using rude or deprecating language can cause your audience to reject your position without carefully considering your claims.

Counterarguments may be located at various locations within your body paragraphs.You may choose to:•build each of your main points as a contrast to oppositional claims.•offer a counterargument after you have articulated your main claims.

Conclusion:

Your conclusion should reemphasize the main points made in your paper.

You may choose to reiterate a call to action or speculate on the future of your topic, when appropriate.

Avoid raising new claims in your conclusion