SOAP NOTE 4 PEDIATRICS/ ACNE

Faculty Comments:  MRU Soap Note Grading Rubric
This sheet is to help you understand what is required, and what the margin remarks might be about on your comments of patients. Since most of your comments that you hand in are uniform, this represents what MUST be included in every write-up.

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: __________________________________

Guidelines for Focused SOAP Notes
• Label each section of the SOAP note (each body part and system).
• Do not use unnecessary words or complete sentences.
• Use Standard Abbreviations
S: SUBJECTIVE DATA (information the patient/caregiver tells you).
Chief Complaint (CC): a statement describing the patient’s symptoms, problems, condition, diagnosis, physician-recommended return(s) for this patient visit. The patient’s own words should be in quotes.
History of present illness (HPI): a chronological description of the development of the patient’s chief complaint from the first symptom or from the previous encounter to the present. Include the eight variables (Onset, Location, Duration, Characteristics, Aggravating Factors, Relieving Factors, Treatment, Severity-OLDCARTS), or an update on health status since the last patient encounter.
Past Medical History (PMH): Update current medications, allergies, prior illnesses and injuries, operations and hospitalizations allergies, age-appropriate immunization status.
Family History (FH): Update significant medical information about the patient’s family (parents, siblings, and children). Include specific diseases related to problems identified in CC, HPI or ROS.
Social History(SH): An age-appropriate review of significant activities that may include information such as marital status, living arrangements, occupation, history of use of drugs, alcohol or tobacco, extent of education and sexual history.
Review of Systems (ROS). There are 14 systems for review. List positive findings and pertinent negatives in systems directly related to the systems identified in the CC and symptoms which have occurred since last visit; (1) constitutional symptoms (e.g., fever, weight loss), (2) eyes, (3) ears, nose, mouth and throat, (4) cardiovascular, (5) respiratory, (6) gastrointestinal, (7) genitourinary, (8) musculoskeletal, (9-}.integument (skin and/or breast), (10) neurological, (11) psychiatric, (12) endocrine, (13) hematological/lymphatic, {14) allergic/immunologic. The ROS should mirror the PE findings section.
0: OBJECTIVE DATA (information you observe, assessment findings, lab results).
Sufficient physical exam should be performed to evaluate areas suggested by the history and patient’s progress since last visit. Document specific abnormal and relevant negative findings. Abnormal or unexpected findings should be described. You should include only the information which was provided in the case study, do not include additional data.
Record observations for the following systems if applicable to this patient encounter (there are 12 possible systems for examination): Constitutional (e.g. vita! signs, general appearance), Eyes, ENT/mouth, Cardiovascular, Respiratory, GI, GU, Musculoskeletal, Skin, Neurological, Psychiatric, Hematological/lymphatic/immunologic/lab testing. The focused PE should only include systems for which you have been given data.
NOTE: Cardiovascular and Respiratory systems should be assessed on every patient regardless of the chief complaint.
Testing Results: Results of any diagnostic or lab testing ordered during that patient visit.
A: ASSESSMENT: (this is your diagnosis (es) with the appropriate ICD 10 code)

List and number the possible diagnoses (problems) you have identified. These diagnoses are the conclusions you have drawn from the subjective and objective data.
Remember: Your subjective and objective data should support your diagnoses and your therapeutic plan.
Do not write that a diagnosis is to be “ruled out” rather state the working definitions of each differential or primary diagnosis (es).
For each diagnoses provide a cited rationale for choosing this diagnosis. This rationale includes a one sentence cited definition of the diagnosis (es) the pathophysiology, the common signs and symptoms, the patients presenting signs and symptoms and the focused PE findings and tests results that support the dx. Include the interpretation of all lab data given in the case study and explain how those results support your chosen diagnosis.
P: PLAN (this is your treatment plan specific to this patient). Each step of your plan must include an EBP citation.
1. Medications write out the prescription including dispensing information and provide EBP to support ordering each medication. Be sure to include both prescription and OTC medications.
2. Additional diagnostic tests include EBP citations to support ordering additional tests
3. Education this is part of the chart and should be brief, this is not a patient education sheet and needs to have a reference.
4. Referrals include citations to support a referral
5. Follow up. Patient follow-up should be specified with time or circumstances of return. You must provide a reference for your decision on when to follow up.

Deep Vein Thrombosis

Case study:

Sandra is a 27-year-old female admitted with a possible Deep Vein Thrombosis (DVT). She smokes one pack per day and is on birth control. She has a history of hypertension and obesity. She is admitted to the hospital and placed on bedrest. Heparin drip is started per protocol. The Provider is anticipating on sending her home with Coumadin.

1. Can Sandra be placed on Coumadin and Heparin at the same time? What is the reason she is on both medications at the same time? Use critical thinking skills and rationale along with data from your resource to support the reason.
2. Develop 3 teaching points important for Sandra to know about her medications regimen.
3. What 3 questions would you ask Sandra to verify that she understand the 3 teaching points?
4. Please include at least 1 reference and provide appropriate citation of your reference(s), only time frame of 2019-2021 is to be used for your references

Number 1 Post: RW

Trichomonas is the most common non-viral sexually transmitted infection in the world.  It is an important source of reproductive morbidity and thus is a public health problem.  However, it is not a reportable disease and surveillance is not generally done.  Most person infected with trichomonas are asymptomatic.  The treatment of choice for women has been metronidazole, for decades, and a single dose has been the first line of defense. (Kissinger, 2015).

Pathogen and Proliferation

Trichomonas vaginalis, a parasitic protozoan, is a etiologic agent of trichomoniasis.  It is a flagellated protozoan possessing five flagella.  Although cell division has been extensively described through the use of microscopy, the life cycle of trichomonas is poorly understood.  Like many other protozoan parasites, it is known to exit only as a trophozoite and lacks a cystic stage.  Trichomonas is a primitive eukaryotic organism.  Although similar to many other eukaryotes it differs in its energy metabolism and shows remarkable similarity to primitive anerobic bacteria. (Petrin et al., 2018).  Trichomonas is a protozoan parasite that tends to destroy epithelial cells and induce pathogenesis. (Lin et al., 2015).

Male partner treatment

The CDC recommends male partners be treated with a single dose of 2g of metronidazole orally.  Concurrent treatment of all sex partners is vital for preventing reinfections.  Current partners should be referred for presumptive therapy.  Partners also should be advised to abstain from intercourse until they and their sex partners have been treated and any symptoms have resolved. (2021).

Metronidazole is a small molecule the enters trichomonas via passive diffusion.  The drug itself is inactive, but anaerobic reduction results in the formation of a cytotoxic nitro radical anion.  The nitro radial is then hypothesized to bind transiently to DNA, disrupting or breaking the strands and leading to cell death.  The action is a short-lived reaction rather than irreversible binding of the drug to DNA. (Cudmore et al., 2004).

Chlamydia

Chlamydia is a sexually transmitted infectious disease caused by the bacterium Chlamydia trachomatis.  It is the most commonly reported bacterial infection, Globally, it is the most common sexually transmitted infection.  It causes an ocular infection called “trachoma”, which is the leading infections cause of blindness worldwide.  In females, the cervix is the site that is most commonly infected. Chlamydial infections in women, especially if untreated, increase the risk of infertility and ectopic pregnancy.  In men, infection with chlamydia can lead to urethritis, epididymitis, prostatitis, proctitis, or reactive arthritis. (Mohseni et al., 2021).

 

 

Number 2 post: PG

A 16-year-old male presents with delayed pubertal signs and social immaturity. His lab values show low testosterone. He was administered GnRH, and no LH was produced. HCG was administered, which restored testosterone to normal levels.

1. Discuss male hypogonadism
2. Explain hormone administration
3. Is there a problem with the hypothalamus? Why or why not?

 

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Male hypogonadism is a testosterone deficiency in men (Dlugasch & Story, 2021). According to Butanis et al. (2017), male hypogonadism results from testosterone or sperm levels in the testes not reaching the proper levels due to disruption of the hypothalamic-pituitary-testicular (HPT) axis. Male hypogonadism causes include congenital, tumors, disease, drug-related, acquired cases, or chronic illness (Salonia et al., 2019). Furthermore, a research study found metabolic syndrome as a causative factor to hypogonadism (Lawrence et al., 2017). In this document, male hypogonadism explored; primary plus secondary are explained; hormone administration explored, and is there a problem with the hypothalamus? Why or why not?

The hypothalamus releases Gonadotropin-releasing hormone (GnRH) in normal physiology (Salonia et al., 2019). Also, in response to GnRH, the anterior pituitary secretes follicle-stimulating hormone (FSH) and luteinizing hormone (LH). Additionally, Sertoli and Leydig cells in the testis are stimulated to produce sperm and testosterone by FSH and LH. Typically, the above occurs in normal physiology. However, problems could arise due to factors that can contribute to hypogonadism. As mentioned earlier, there are two types of hypogonadism: primary and secondary. Primary hypogonadism stems from an inherent defect within the testes (Salonia et al., 2019). Therefore, low or absent testosterone levels are accompanied by high gonadotropin levels in the condition (Salonia et al., 2019).

Additionally, spermatogenesis is often severely impaired and may not respond to hormonal treatment (Salonia et al., 2019). Secondary hypogonadism (also known as central hypogonadism or hypogonadotropic hypogonadism) results from hypothalamic or pituitary dysfunction (Salonia et al., 2019). The biochemical characteristics of this condition are low or inappropriately normal gonadotropin levels and low total testosterone levels (Salonia et, 2019). Moreover, spermatogenesis is impaired, but treatment usually improves it (Salonia et ., 2019).

Clinicians should perform tests to determine if the condition is primary or secondary and treat accordingly (Lawrence et al., 2017). Also, patient education and management guidelines are vital during treatment. For example, Salonia et al. (2019) informed testosterone therapy for congenital cases of hypogonadism is lifelong, and management of acquired care depends on whether the condition can be managed or if the state is permanent. Treatment may consist of replacing testosterone to raise the level in the blood and assist in countering the symptoms of male hypogonadism (Salonia et al., 2019). Treatment, for instance of testosterone, comes in various forms, such as injectables, esters, gels, nasal gels, or oral (Salonia et al. 2019). Also, Salonia et al. (2019) mentioned treatment of males less than ten should be treated with caution due to bone age and that high doses could cause premature epiphyseal closure.

According to Mayo Clinic (2022), in male hypogonadism, one could be born with a congenital condition or develop later in life. As mentioned above, the primary problem is with the testes (Mayo clinic, 2022). However, this type of hypogonadism in secondary could indicate a problem in the hypothalamus or the pituitary gland (Mayo clinic, 2022). Moreover, The hypothalamus produces gonadotropin-releasing hormones, which cause the pituitary to produce follicle-stimulating hormones and luteinizing hormones (Mayo clinic, 2022). In addition, luteinizing hormones stimulate testosterone production in the testes (Mayo clinic, 2022).

In closing, hypogonadism is a testosterone deficiency in males, and supplemental steroids may aid in relieving symptoms of this disorder and raise the blood level of the hormone. The problem of hypogonadism may lie with the testes or central (in the brain) like the hypothalamus or pituitary gland. As professionals in health care, monitoring steroid use, client education, and client, plus steroid guidelines are vital in managing the disorder.

 

      

MATERNALCHILD06–Child Observation Worksheet

TOPIC: Child Observation Worksheet

 

Purpose of Assignment

This assignment will help to identify the normal growth and development by topic for each age group. In the final column of the assignment, you need to observe a child and apply the information you gathered and document your findings in comparison by the particular age of that child.

 

Competency

Compare principles of growth and development when caring for pediatric clients.

Explain the topics in the worksheet by age. Identify one milestone and one expected norm for each category by age group.

 

After you fill out the milestones and expected norms for each category by age group, imagine observe a child of any age for 30 minutes to an hour, and apply the knowledge that you learned to the child you are observing and record this information in the purple Observation Data column.

 

 

NO CONSIDERATION FOR PLAGIARISM

APA FORMAT AND INDEX CITATION, REFERENCES THREE

PLEASE WRITE FROM NURSING PERSPECTIVE

 

DUE 2/7/22 AT 11AM

 

 

 

 

FOLLOW ALL Rubric Details CORRECTLY TO AGAIN FULL POINTS

 

• Content and Mechanics

50% of total grade

Mastery: Advanced or exceeds achievement

Contains thorough details by age group to represent the topic identified. Information is current.

30

Proficiency: Clear/effective achievement

Contains sufficient details by age group to represent the topic identified. Information is current.

27.9

Competence: Adequate/basic achievement

Contains some details by age group to represent the topic identified. Information is mostly current.

25.2

Emerging: Limited or growing achievement

Details are minimal or non-existent.

19.5

• Client Data

40% of total grade

Mastery: Advanced or exceeds achievement

Observation data is documented with extensive details.

24

Proficiency: Clear/effective achievement

Observation data is documented with sufficient details.

22.32

Competence: Adequate/basic achievement

Observation data is documented with some details.

20.16

Emerging: Limited or growing achievement

Observation data is incomplete.

15.6

• Spelling and Grammar

5% of total grade

Mastery: Advanced or exceeds achievement

Demonstrates an exemplary application of spelling and grammar.

3

Proficiency: Clear/effective achievement

Displays proper grammar application and writing contains minimal to no spelling errors. May contain rare improper uses of words (ex., their vs. there), a misplaced modifier, or a run-on sentence, but does not detract from the overall understanding of the sentence and/or paragraph.

2.79

Competence: Adequate/basic achievement

Spelling and grammar errors occur but are inconsistent. Paragraphs and sentences are coherent but may exhibit spelling errors, run-on’s or fragments, and/or improper verb tense usage.

2.52

Emerging: Limited or growing achievement

Spelling and grammar contain substantial errors that makes sentences and/or paragraphs incoherent.

1.95

• APA Style

5% of total grade

Mastery: Advanced or exceeds achievement

APA citations are free of style and formatting errors.

3

Proficiency: Clear/effective achievement

Errors in APA citations are less noticeable and do not detract from the ability to locate the original source (for example, a missing or misused comma or period, missing parentheses, author name not properly abbreviated, indentation is misaligned).

2.79

Competence: Adequate/basic achievement

Errors in APA citations are noticeable and may detract from the ability to locate the original source (for example, no title provided, year of publication is missing, no punctuation).

2.52

Emerging: Limited or growing achievement

Citations do not follow APA Style. Quotations, paraphrases, and summaries are not cited, or there is no attempt to cite them using APA style.

1.95

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Module 06 Worksheet- Development Assignment

	Infancy	Toddler	Pre School	School Age	Adolescent	Observation Data for [insert age, gender, and any other relevent information]. Example: Female, Age 4, Autistic. *only fill out this column for the age group you observed.
Erikson’s Theory
Cognitive Development
Language Development
Psych-Social Development
Moral Development
Discipline
Physical Development
Injury Prevention
Nutritional needs
Dental Care
Sleep
Activity and Play types
Vital Signs Including type of Pain assessment

 

 

MATERNALCHILD_Module 09 Discussion – Pediatric Safety

TOPIC: – Pediatric Safety

 

Purpose of Assignment

Part 2

This assignment will address the current issues in pediatric healthcare related to safety. Growth and development is an important factor that should be considered along with safety in many areas of pediatric health alterations. Many times, the health alterations experienced by children can be prevented if safety education is provided.

Competency

Prioritize nursing interventions when caring for pediatric clients with health disorders.

Instructions

This assignment will focus on the importance of teaching a chosen safety concern in the pediatric population. You will present your response in this assignment addressing the following questions: (assignment should be 300 words).

Initial Post:

1. Determine the age and developmental stage and how that impacts the child related to the safety concern.
2. Describe why you believe the safety education you chose will benefit the pediatric population. Who do you believe is the target age range for this specific educational teaching?
3. Describe at least three nursing diagnoses related to the incident you are providing teaching to prevent. Support your choices with rationales citing three scholarly sources.

Part 2 400 words

Discuss two different safety education than you chose in part 1 and add additional rationale for why this type of education is beneficial. Cite four scholarly sources to support each.

 

NO CONSIDERATION FOR PLAGIARISM

APA FORMAT AND INDEX CITATION

PLEASE WRITE FROM NURSING PROSPECTIVE

 

DUE 2/15/22