Monthly Archives: May 2023

SOAP NOTE

Name: N.C

Date: 10/26/2020

Time: 09.30 h

Age: 5-year-old

Sex: M

CC: “I have sore throat”

HPI: 

A 5 y/o Hispanic male presents to the clinic complaining of sore throat that started 3 days ago. Describes that occasionally feels like “piercing or burning” pain that it is constant. Also, that is very painful to swallow. Mother states patient developed cold symptoms (cough, sneezing) about 5 days ago, sore throat started 3 days ago, and fever of 101.5 F began 24h ago. Patient added that the pain varies in intensity, rated anywhere from 8 to 9 on a Wong-Baker scale when eating or drinking, but at this moment rated his pain at 5. Reports that pain is not radiating to any surrounded area and “is better when drinking sips of a cold liquids like water or Kool-Aid or takes Ice cream”. Mother also states that fever somehow is relieved by rest and Tylenol. Confirms that his appetite has decreased in the last 3 days.

Medications: 

Tylenol OTC PO PRN

PMH 

Allergies: NKDA

Medication Intolerances: None

Chronic Illnesses/Major traumas: None

Hospitalizations/Surgeries: None

Immunizations: 

– According to CDC for his age group, he is up to date with the following vaccines

•          Influenza 2019

•          Tdap 5th dose

•          MMR 2nd dose

•          Polio IVP 4th dose

•          Chickenpox (Varicella) 2nd dose

Family History:

Mother: Alive – no significant medical history

Father: Alive – HTN

Sister: 8 years old healthy

Brother: 2 days old healthy

Social History

Lives with both parents and siblings. Appears comfortable and happy with mother in the room. Neither parents smoke. Patient began kindergarten this year at local public school.

General 

Patient reports sore throat, but overall healthy, appropriate weight and height for age, usually very active but mostly lying around the past few days per mom.

Cardiovascular

Denies chest pain or palpitations.

Skin

Denies rash, inflammation, pain, tenderness, or skin lesion.

Respiratory

Denies any cough, wheezing, hemoptysis, dyspnea, pneumonia hx, TB exposure or symptoms per mom, or SOB.

Eyes

Denies use of corrective lenses or glasses, blurred vision, or visual changes of any kind.

ENT

Denies ear pain, hearing loss, ringing in ears, discharge. Reports no sinus problems, or nose bleeding. Complains of sore throat and aggravating pain when swallowing. Goes to dentist every 6 months per mom.

Gastrointestinal

Denies diarrhea, abdominal pain, or heartburn. He had his last bowel movement this morning and goes at least once a day.

Genitourinary

Denies urgency, frequency or burning and pain with urination. Reports no hematuria or change in color of urine. Denies penile pain.

Musculoskeletal

Denies back pain, joint swelling, stiffness, or muscle pain.

Heme/Lymph/Endo 

Denies fatigue. Mother states swollen/tender cervical lymph nodes. Patient is appropriate size and weight for his age.

Neurological

Denies any syncope, seizures, transient paralysis, paresthesia or black out spells per mom.

Psychiatric

Denies any nightmares; patient seems happy and answers questions appropriately when asked directly.

OBJECTIVE – 

Weight  47.6 lbs.    BMI 15.1          Temp 100.1F  BP 103/67

Height 47”     Pulse 108       Resp 18

General Appearance

Happy. Alert and oriented in all spheres; answers questions appropriately when asked directly, but otherwise shy. Cooperative.

Skin

Skin is warm, dry, no rashes or lesion noted.

HEENT

Head is normocephalic, atraumatic and without lesions. EYES: Extra ocular muscles intact, PERRLA. Ears: TM’s shiny, EAC clear, hearing intact, mild tympanic membrane bulging. Nose: Bilateral turbs red and swollen, septum midline. Throat: Posterior pharyngeal erythema, white pus pockets noted on swollen tonsils.

Cardiovascular

S1, S2 with regular rate and rhythm. No extra sounds, clicks, rubs, or murmurs.

Respiratory

Symmetric chest wall. Respirations regular and unlabored; lungs clear to auscultation in all fields bilaterally.

Gastrointestinal

Abdomen is flat, BS normoactive in all 4 quadrants. No hepatosplenomegaly, soft no tender on palpation. Bowel sound normoactive in all 4 quadrants.

Lymphatic

Swollen cervical nodes bilaterally, tenderness on palpation.

Genitourinary

Bladder is non-distended, non-tender. External genitalia normal, no lesions observed. Tanner Stage 1.

Musculoskeletal

Full ROM seen in all 4 extremities without any difficulties.

Neurological 

Speech clear. Good tone. Posture is erect, balance stable and gait is normal.

Psychiatric

Alert and oriented. Maintains good eye contact. Speech is soft, and clear and of normal rate and cadence for age. Answers questions appropriately when asked directly, otherwise shy. Displays no mood disorders.

Lab Tests

CBC, CMP: pending

Special Tests

Strep Swab: Positive

Culture and sensitivity of tonsils exudate: pending

Primary Diagnosis

•          J02.0 Streptococcal Pharyngitis: Common signs and symptoms of streptococcal pharyngitis include sore throat, temperature greater than 100.4°F (38°C), tonsillar exudates, and cervical adenopathy. Cervical node lymphadenopathy and pharyngeal or tonsillar inflammation or exudates are common signs. Palatal petechiae and scarlatiniform rash are highly specific but uncommon; a swollen uvula is sometimes noted. Available diagnostic tests include throat culture and rapid antigen detection testing. Throat culture is considered the diagnostic standard, although the sensitivity and specificity of rapid antigen detection testing have improved significantly.

Differential Diagnoses: 

•          J03.90 Acute Tonsillitis: Tonsillitis is most often a viral infection caused by cold viruses and starts suddenly and lasts for a week or two. Patients with tonsillitis typically present with a sore throat, swollen tonsils that are erythematous, and have a yellowish coating, difficulty swallowing, fatigue, fever, and loss of appetite (IQWiG, 2019). The patient in this case study does not have any coating of the tongue, loss of appetite, or fatigue noted so this is not likely to be the primary diagnosis.

•          B27.9 Infectious mononucleosis: Mononucleosis is caused by the Epstein Barr Virus and it is common to have inflammation of the tonsils with exudates which can also present with a generalized abdominal pain (Ruppert, 2015). This patient is middle aged and therefore, it is less likely that this is the diagnosis as it is not commonly seen in adults, but rather in adolescent to young adults between 15 to 24 years old. There is a test for mononucleosis called the Monospot test; however, it takes several weeks for a positive result to appear. This often tends to be inconvenient and often it is treated based on symptoms alone (Lyden, 2017). This is not likely to be the diagnosis for this patient as patients with mononucleosis have severe malaise and fatigue, which this patient has not reported.

•          D24.1 Acute pharyngitis: Pharyngitis is caused by inflammation to the pharynx and can occur in both adults and children and is due to either infection or irritation (Lyden, 2017). This is a very common condition and can be either viral or bacterial in nature. Bacterial pharyngitis is most commonly a result of a group A strep infection and according to Lyden (2017), it presents with erythema of the tonsils or throat, exudate which can be discrete or patchy, white or yellow, pharyngeal petechiae, and tenderness in the anterior cervical adenopathy. Viral pharyngitis is almost always caused by the rhinovirus and presents with cough, mild erythema, nasal drainage or stuffiness, fever, but no tenderness or lymphadenopathy (Lyden, 2017). This patient most likely has bacterial pharyngitis as the neck is tender with enlarged anterior cervical lymph nodes.

Plan/Therapeutics/Referrals/Education

Plan: 

1.        Children’s Motrin Oral suspension q8h PRN for pain and fever

2.        Amoxicillin 400/5ml Oral suspension for 10 days

3.        Advised to follow-up in 1 week to ensure medication course was followed and was effective.

4.        Results of all tests to be reviewed with patient in 1-week follow-up appointment.

Referrals:

No referral currently.

Patient Education:

–          Stop Tylenol and start with the prescribed NSAID.

–          Take the prescribed antibiotics for full treatment even if symptoms seem better in a few days. Do not stop earlier.

–          Increase cold fluid intake.

–          Saltwater gargles at least 3 times daily.

–          Rest, and no school until fever free for 24 hours.

–          If symptoms worsen direct yourself to the nearest ER.

References

Institute for Quality and Efficiency in Health Care (IQWiG) (January 17, 2019). Tonsillitis: Overview. Retrieved from: https://www.ncbi.nlm.nih.gov/books/NBK401249/

Lyden, E. A. (2017). Chapter 101: Pharyngitis and Tonsillitis. In T. Buttaro, J. Trybulski, P. Polgar-Bailey, & J. Sandberg-Cook (Eds.), Primary care: A collaborative practice (5th ed., pp. 413-416). St. Louis, MO: Elsevier

Soap Note 1 Acute Conditions

Follow the MRU Soap Note Rubric as a guide:

Use APA format and must include minimum of 2 Scholarly Citations.

right otitis media

has to be a 17 years old male with no others pathologic associated, treatment has to include acetaminophen and cephalosporin. 

template format is attached

As a psychiatric nurse practitioner, before you can recommend potential pharmacotherapeutics to address a patient’s condition or disorder, you must understand the basic function and structure of the neuron and central nervous system. For this Assignment, you will review and apply your understanding of neuroanatomy by addressing a set of short-answer prompts.

To Prepare:

· Review the Learning Resources for this week in preparation to complete this Assignment.

· Reflect on the basic function and structure of the neuron in relation to the central nervous system.

· Reflect on the inter-connectedness between neurons and the central nervous system, including the pathway and distribution of electrical impulses.

· Reflect on how neurons communicate with each other and review the concept of neuroplasticity.

To complete:

Address the following Short Answer prompts for your Assignment. Be sure to include references to the Learning Resources for this week.

1. In 4 or 5 sentences, describe the anatomy of the basic unit of the nervous system, the neuron. Include each part of the neuron and a general overview of electrical impulse conduction, the pathway it travels, and the net result at the termination of the impulse. Be specific and provide examples.

2. Answer the following (listing is acceptable for these questions):

o What are the major components that make up the subcortical structures?

o Which component plays a role in learning, memory, and addiction?

o What are the two key neurotransmitters located in the nigra striatal region of the brain that play a major role in motor control?

3. In 3 or 4 sentences, explain how glia cells function in the central nervous system. Be specific and provide examples.

4. The synapse is an area between two neurons that allows for chemical communication. In 3 or 4 sentences, explain what part of the neurons are communicating with each other and in which direction does this communication occurs? Be specific.

5. In 3–5 sentences, explain the concept of “neuroplasticity.” Be specific and provide examples.

Hi,

I completed my research with the answer above.  Please reviewed and correct my paper by tomorrow before 12:00pm.  Thanks.

Tim.

1) Minimum 8 full pages (Follow the 3 x 3 rule: minimum three paragraphs per part)

              Part 1: Minimum 1 page

              Part 2: minimum 1 page

              Part 3: minimum 1 page

              Part 4: minimum 1 page 

              Part 5: Minimum 1 page

              Part 6: minimum 1 page

              Part 7: minimum 1 page

              Part 8: minimum 1 page

Submit 1 document per part

2)¨******APA norms

          All paragraphs must be narrative and cited in the text- each paragraphs

          Bulleted responses are not accepted

          Dont write in the first person 

          Dont copy and pase the questions.

          Answer the question objectively, do not make introductions to your answers, answer it when you start the paragraph

         Submit 1 document per part

3)****************************** It will be verified by Turnitin (Identify the percentage of exact match of writing with any other resource on the internet and academic sources, including universities and data banks) 

********************************It will be verified by SafeAssign (Identify the percentage of similarity of writing with any other resource on the internet and academic sources, including universities and data banks)

4) Minimum 3 references per part not older than 5 years

5) Identify your answer with the numbers, according to the question.

Example:

Q 1. Nursing is XXXXX

Q 2. Health is XXXX

6) You must name the files according to the part you are answering: 

Example:

Part 1.doc 

Part 2.doc 

__________________________________________________________________________________

Part 1: 

 Topic: Infection control and prevention

Dissemination of EBP and research, such as presenting results at a conference or writing an article for a journal, is an important part of professional practice. 

Infection control and prevention

1. Identify one professional journal and one nursing or health care conference where you might present your project. 

2. Discuss why each of your choices is the best option for you to disseminate your new knowledge.

Part 2: 

 Topic: Infection control and prevention

1. Discuss why EBP is an essential component of the practice of a BSN-prepared RN. 

2. Identify two ways in which you will continue to integrate evidence into your practice and encourage it within your work environment. 

3. What obstacles could challenge this plan, and what steps will you take to minimize their impact?

Part 3: 

Case Study:

Richard is a 40-year-old man with a history of 4 weeks of cluster headache once each year. These began when he was 35 years old. His cluster periods occur in the fall. The cluster period begins slowly, increasing over 1 week, reaching a peak where Richard has two or three severe cluster attacks each day. They occur from 10 p.m. to 3 a.m. Each cluster headache lasts from 40 to 90 minutes, and the headaches are severe. The pain is always on the right side, with eye tearing and nasal congestion. 

Richard comes into our office 1 week into this fall’s cluster series. The headaches are increasing in intensity, and he is miserable with the pain.

Please complete the following questions: 

1. Describe Cluster Headache and its epidemiology.

2. What would be your goals for therapy for Richard? Give rationale with evidence from articles. 

 Part 4: Community Nursing

A neighbor, who is 3 months pregnant, asks to talk to you because she has felt tired for the last 2 days, has a headache, a rash, and does not feel like eating. You take her vital signs and find that she has a low-grade fever. She has recently traveled to an area where there is risk for Zika virus disease.

1. To what could your neighbor have been exposed

2. how could the exposure have occurred?

3. What advice would you give your neighbor?

Part  5: Crisis intervention 

 1. Discuss what is complicated grieving.

2.  Mention at least 3 clues for identifying complicated grief reaction and explain them. 

Part 6: Aging

When caring for older adults, it is important for the nurse to understand special considerations for medication use in the older population. 

1. List at least two considerations and education you would provide for following medication: Analgesics: Aspirin, acetaminophen and Diuretics: Thiazides, loop diuretics, potassium-sparing diuretics?

You are the nurse caring for an 82-year-old patient with a diagnosis of: Ineffective Breathing Pattern. 

2. List two (2) interventions for this diagnosis with supporting rational. +

Part 7

Clinical performance evaluation is subjective and involves the judgments of the evaluator. It is filtered by the evaluator’s perspective, values, and biases. With this in mind, 

1. select three clinical evaluation strategies that you believe are fair and accurate in order to measure student learning, and determine their competency and safety in the clinical setting.

2.  Explain your rationale for why you selected each of the strategies, and how they align with your personal philosophy of teaching.  

Make sure the strategies that you selected include ways to evaluate students cognitive, psychomotor, and affective domains of learning.

Part 8

What is your position on assigning grades based on a curve (a relative scale)? Explain and defend your position.

Reply to this discussion (site sources if applicable)

Workplace Violence-Preventing and Improving the Outcomes 

     After discussing different aspects of change with my preceptor, we discovered ways to improve my evidence-based practice implementation. Developing an evidence-based change proposal can be challenging in any aspect. One financial aspect of preventing and managing workplace violence is hiring more security guards to be present in difficult situations. Also, having security guards that are properly trained to intervene and provide interventions to help hospital staff when needed with the use of restraints or the use of physically restraining a difficult patient that is causing disruption and health care staff are unable to safely care for the patient. Improving a quality aspect of workplace violence would be to decrease the rates of WPV, promote a safe working environment with signage and verbal reminders. Workplace violence can be in the form of verbal, confrontation, harassment, intimidation, and physical violence. All these forms of violence can cause harm emotionally and physically to nurses, physicians and other healthcare providers. Reporting of these incidents can help with collecting data and this data should be reported and analyzed by management teams for incident tracking. Due to the limited reporting of incidents, staff should be better trained and educated on the need for reporting (Alqahtani, Alsaleem & Qassem, 2020). With these quality improvements, we can create a safer healthcare organization. A clinical aspect of managing workplace violence in the workplace is ensuring proper training, real-life scenarios and providing a safe workplace environment free from potential hazards. Administration teams and management teams need to provide the proper training, in order for nurses to be better prepared for violence and how to handle each situation.  My implementation of creating a zero-tolerance for violence in the Emergency Department will help create a safer environment.  Nurses are constantly being abused physically and verbally and increasing awareness, reporting and training can hopefully help reduce the number of incidents.

Required Readings

Wheeler, K. (Ed.). (2014). Psychotherapy for the advanced practice psychiatric nurse: A how-to guide for evidence-based practice (2nd ed.). New York, NY: Springer Publishing Company.
Chapter 7, “Motivational Interviewing” (pp. 299–312)
Chapter 16, “Psychotherapeutic Approaches for Addictions and Related Disorders” (pp. 565–596)

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.

Albrecht, U., Kirschner, N. E., & Grusser, S. M. (2007). Diagnostic instruments for behavioral addiction: An overview. German Medical Science Psycho-Social-Medicine, 4, 1–11. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2736529/

Fisher, M. A. (2016a). The ethical ABCs of conditional confidentiality. In Confidentiality limits in psychotherapy: Ethics checklists for mental health professionals (pp. 13–25). Washington, DC: American Psychological Association. doi:10.1037/14860-002.

To prepare:

• Review this week’s Learning Resources and consider the insights they provide.
• Review the Levy Family video Episodes 1 through 5.

The Assignment

In a 2- to 3-page paper, address the following:

• After watching Episode 1, describe:
  • What is Mr. Levy’s perception of the problem?
  • What is Mrs. Levy’s perception of the problem?
  • What can be some of the implications of the problem on the family as a whole?
• After watching Episode 2, describe:
  • What did you think of Mr. Levy’s social worker’s ideas?
  • What were your thoughts of her supervisor’s questions about her suggested therapies and his advice to Mr. Levy’s supervisor?
• After watching Episode 3, discuss the following:
  • What were your thoughts about the way Mr. Levy’s therapist responded to what Mr. Levy had to say?
  • What were your impressions of how the therapist worked with Mr. Levy? What did you think about the therapy session as a whole?
  • Informed by your knowledge of pathophysiology, explain the physiology of deep breathing (a common technique that we use in helping clients to manage anxiety). Explain how changing breathing mechanics can alter blood chemistry.
  • Describe the therapeutic approach his therapist selected. Would you use exposure therapy with Mr. Levy? Why or why not? What evidence exists to support the use of exposure therapy (or the therapeutic approach you would consider if you disagree with exposure therapy)?
• In Episode 4, Mr. Levy tells a very difficult story about Kurt, his platoon officer.
  • Discuss how you would have responded to this revelation.
  • Describe how this information would inform your therapeutic approach. What would you say/do next?
• In Episode 5, Mr. Levy’s therapist is having issues with his story.
  • Imagine that you were providing supervision to this therapist, how would you respond to her concerns?
• Support your approach with evidence-based literature.

Analysis of a Pertinent Healthcare Issue (lack of access to healthcare)

Develop a 3- to 4-page paper, written to your organization’s leadership team, addressing your selected national healthcare issue/stressor and how it is impacting your work setting. Be sure to address the following:

• Describe the national healthcare issue/stressor you selected and its impact on your organization. Use organizational data to quantify the impact (if necessary, seek assistance from leadership or appropriate stakeholders in your organization).
• Provide a brief summary of the two articles you reviewed from outside resources on the national healthcare issue/stressor. Explain how the healthcare issue/stressor is being addressed in other organizations.
• Summarize the strategies used to address the organizational impact of national healthcare issues/stressors presented in the scholarly resources you selected. Explain how they may impact your organization both positively and negatively. Be specific and provide examples.