SU NSG6001 Week 4 Assignment Latest 2019 September

NSG6001 Advanced Nursing Practice

Week 4 Assignment

SOAP Note Assignment

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.

Download the access
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_W4A2_LastName_FirstInitial.doc.

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

Week 4: Genitourinary
Clinical Case

© 2016 South
University

Week 4: Genitourinary
Clinical Case 2

Patient Setting:

28-year-old female presentsto
the clinic with a 2 day history of frequency, burning and pain upon

urination; increased
lower abdominal pain and vaginal discharge over the past week.

HPI

Complains of urinary
symptomssimilarto those of previous urinary tractinfections(UTIs) which started

approximately 2 days
ago; also experiencing severe lower abdominal pain and noted brown fouls

smelling discharge
after having unprotected intercourse with her former boyfriend.

PMH

Recurrent UTIs (3 this
year); gonorrhea X2, chlamydia X 1; Gravida IV Para III

Past Surgical History

Tubal ligation 2 years
ago.

Family/Social History

Family: Single;
history ofmultiplemale sexual partners; currently lives with newboyfriend and 3

children.

Social: Denies
smoking, alcohol and drug use.

Medication History

None

Allergy: Trimethoprim
(TOM)/ Sulfamethoxazole (SMX) -Rash

ROS

Last pap 6 months ago,
Denies breast discharge.Positive for Urine looking dark.

Physical exam

BP 100/80,

HR 80,

RR 16,

T 99.7 F,

Wt 120,

Ht 5’ 0”

Gen: Female in
moderate distress.

HEENT: WNL.

Cardio: Regularrate
and rhythm normal S1 and S2.

Chest: WNL.

Abd: soft, tender,
increased suprapubic tenderness.

GU: Cervical motion
tenderness, adnexal tenderness, foul smelling vaginal drainage.

Rectal: WNL.

Page 2 of 3

Advanced Nursing
Practice I

©2016 South University

Week 4: Genitourinary
Clinical Case 3

EXT: WNL.

NEURO: WNL.

Laboratory and
Diagnostic Testing

Lkc differential:
Neutraphils 68%, Bands 7%, Lymphs 13%, Monos 8%, EOS 2%

UA: Starw colored. Sp
gr 1.015, Ph 8.0, Protein neg, Glucose neg, Ketones neg, Bacteria – many, Lkcs
10-

15, RBC 0-1

Urine gram stain –
Gram negative rods

Vaginal discharge
culture:Gramnegativediplococci,Neisseriagonorrhoeae,sensitivities pending

Positive monoclonal AB
for Chlamydia, KOH preparation,Wet preparation and VDRL negative

Page 3 of 3

Advanced Nursing
Practice I

©2016 South University