28 Dec Download and analyze the

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.

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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

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Advanced Nursing Practice I

©2016 South University