SU NSG6001 Week 2 Assignment Latest 2019 September

NSG6001 Advanced Nursing Practice

Week 2 Assignment

SOAP Note Assignment

Click here to download
and analyze the case study for this week. Create a SOAP note for disease
prevention, health promotion, and acute care of the patient in the clinical
case. Your care plan should be based on current evidence and nursing standards
of care.

Visit the online
library and research for current scholarly evidence (no older than 5 years) to
support your nursing actions. In addition, consider visiting government sites such
as the CDC, WHO, AHRQ, Healthy People 2020. Provide a detailed scientific
rationale justifying the inclusion of this evidence in your plan.

Next determine the
ICD-10 classification (diagnoses). The International Classification of
Diseases, Ninth Revision, Clinical Modification (ICD-10-CM) is the official
system used in the United States to classify and assign codes to health conditions
and related information.

Click here to access
the codes.

Download the SOAP
template to help you design a holistic patient care plan. Utilize the SOAP
guidelines to assist you in creating your SOAP note and building your plan of
care. You are expected to develop a comprehensive SOAP note based on the given
assessment, diagnosis, and advanced nursing interventions. Reflect on what you
have learned about care plans through independent research and peer discussions
and incorporate the knowledge that you have gained into your patient’s care
plan. If the information is not in the
provided scenario please consider it normal for SOAP note purposes, if it is
abnormal please utilize what you know about the disease process and write what
you would expect in the subjective and objective areas of your note.

Format

Your care plan should
be formatted as a Microsoft Word document. Follow the current APA edition
style. Your paper should be no longer than 3-4 pages excluding the title and
the references and in 12pt font.

Name your document:
SU_NSG6001_W2A2_LastName_FirstInitial.doc.

Submit your document
to the Submissions Area by the due date assigned.

Week 2: Respiratory
Clinical Case

Patient Setting:

65 year old Caucasian
female that was discharged from the hospital 10 weeks ago after a motor vehicle

accident presents to
the clinic today. States she is having severe wheezing, shortness of breath and

coughing at least once
daily. She can barely get her words out without taking breaks to catch her
breath

and states she has
taken albuterol once today.

HPI

Frequent asthma
attacks for the past 2 months (more than 4 times per week average), serious MVA
10

weeks ago; post
traumatic seizure 2 weeks after the accident; anticonvulsant phenytoin started
– no

seizure activity since
initiation of therapy.

PMH

History of periodic
asthma attacks since early 20s; mild congestive heart failure diagnosed 3 years
ago;

placed on sodium
restrictive diet and hydrochlorothiazide; last year placed on enalapril due to

worsening CHF;
symptoms well controlled the last year.

Past Surgical History

None

Family/Social History

Family: Father died
age 59 of kidney failure secondary to HTN; Mother died age 62 of CHF

Social: Nonsmoker; no
alcohol intake; caffeine use: 4 cups of coffee and 4 diet colas per day.

Medication History

Theophylline SR Capsules
300 mg PO BID

Albuterol inhaler, PRN

Phenytoin SR capsules
300 mg PO QHS

HTCZ 50 mg PO BID

Enalapril 5 mg PO BID

Allergies

NKDA

ROS

Positive for shortness
of breath, coughing, wheezing and exercise intolerance. Denies headache,

swelling in the extremities
and seizures.

Physical exam

BP 171/94, HR 122, RR
31, T 96.7 F, Wt 145, Ht 5’ 3”

VS after Albuterol
breathing treatment – BP 134/79, HR 80, RR 18

Gen: Pale, well
developed female appearing anxious. HEENT: PERRLA, oral cavity without lesions,
TM

without signs of
inflammation, no nystagmus noted. Cardio: Regular rate and rhythm normal S1 and
S2.

Chest: Bilateral
expiratory wheezes. Abd: soft, non-tender, non-distended no masses. GU:

Unremarkable. Rectal:
Guaiac negative. EXT: +1 ankle edema, on right, no bruising, normal pulses.

NEURO: A&O X3,
cranial nerves intact.

Laboratory and
Diagnostic Testing

Na – 134

K – 4.9

Cl – 100

BUN – 21

Cr – 1.2

Glu – 110

ALT – 24

AST – 27

Total Chol – 190

CBC – WNL

Theophylline – 6.2

Phenytoin – 17

Chest Xray – Blunting
of the right and left costophrenic angles

Peak Flow – 75/min;
after albuterol – 102/min

FEV1 – 1.8 L; FVC 3.0
L, FEV1/FVC 60%