CODING

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SOAP Note 1

Maria Rodriguez

Age: 25 y.o.

Ethnicity: Hispanic

Past Medical history: None

Past Surgical History: Tonsillectomy age 7

Medications: none

Family history: Mother Diabetes, Father Hyperlipidemia

Employment: works as a phlebotomist full time

S: Maria is an established patient who presents to office today for birth control. Pt is in a monogamous relationship with her current boyfriend of 4 months and is using condoms 100% of the time. Pt would like to start a more reliable form of birth control. Menarche 12 y.o menses: every 28 days and lasts for 5 days, patient denies cramps or irregular menses history. Patient is a non-smoker and does not use any substances. Last pap was 6 months ago negative for cytology. Gonorrhea and Chlamydia culture 6 months ago was neg/neg. HPV vaccine completed.

O: 5 feet 6 inches 140 pounds 98.4-80-16-122/76

General: Healthy appearing Hispanic woman in no apparent distress

Skin: No skin lesions identified

Head: Normocephalic, good hair distribution, no alopecia no nits

Eyes: Symmetrical with no erythema or discharge. Vision grossly normal

Ears: Symmetrical with gross hearing intact

Nose: midline, no septal defect, no discharge

Mouth: good dentition, moist mucous membranes

Cardiac: HR 80 normal sinuses rhythm, no S3 or S4, no arrhythmias noted

Lungs: Clear to auscultation bilaterally A & P, no use of accessory muscles

Abdomen: flat, soft, non-distended. Bowel sounds active in all 4 quadrants, tympanic throughout, no hepatosplenomegaly, no rebound or guarding.

A: Contraception Counseling

P: Diagnostics up to date

Education: During the 20-minute face-to-face visit, I discussed with patient the various forms of contraception including barrier, hormonal, non-hormonal, abstinence and natural family planning. Discussed efficacy, cost, risks and benefits of each method, using the Birth control option handout. Discussed timing to start method and how to use method to ensure efficacy. Patient decided to start oral contraceptives. Discussed Sunday start, daily dosing, missed pills, common side effect and major side effects, such as ACHES and when to call.

Continue Condom use for STD prevention

Pharm: Ortho-Tricyclen 28 day, 1 pill every day to start on Sunday after first day of menses. 3 refills

Referrals: none

Follow- up: 3 months

Module 09 Discussion – Pediatric Safety

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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 discussion will focus on the importance of teaching a chosen safety concern in the pediatric population. You will present your response in the discussion addressing the following questions: (discussion 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 1-2 scholarly sources.

CASE STUDY: Active Labor: Susan Wong

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Instructions: Read the following case study and answer the reflective questions. Please provide rationales for your answers. Make sure to provide citations/references for your answers in APA format.

CASE STUDY: Active Labor: Susan Wong

Mrs. Wong, a first-time mother, is admitted to the birthing suite in early labor after spontaneous rupture of membranes at home. She is at 38 weeks of gestation with a history of abnormal alpha-fetoprotein levels at 16 weeks of pregnancy.

She was scheduled for ultrasonography to visualize the fetus to rule out an open spinal defect or Down syndrome, but never followed through. Mrs. Wong and her husband disagreed about what to do (keep or terminate the pregnancy) if the ultrasonography indicated a spinal problem, so they felt they did not want this information.

Reflective Questions

1.  As the nurse, what priority data would you collect from this couple to help define relevant interventions to meet their needs?

2.  How can you help this couple if they experience a negative outcome in the birthing suite? What are your personal views on terminating or continuing a pregnancy with a risk of a potential anomaly? What factors may influence your views?

3.  With the influence of the recent Human Genome Project and the possibility of predicting open spinal defects earlier in pregnancy, how will maternity care change in the future?

MSN 5550 Health Promotion: Prevention of Disease Case Study Module 8 Instructions: Read the following case study and answer the reflective questions. Please provide rationales for your answers. Make sure to provide citations/references for your answers in APA format. Deadline: Due by Sunday at 23:59 p.m.

CASE STUDY: Active Labor: Susan Wong Mrs. Wong, a first-time mother, is admitted to the birthing suite in early labor after spontaneous rupture of membranes at home. She is at 38 weeks of gestation with a history of abnormal alpha-fetoprotein levels at 16 weeks of pregnancy. She was scheduled for ultrasonography to visualize the fetus to rule out an open spinal defect or Down syndrome, but never followed through. Mrs. Wong and her husband disagreed about what to do (keep or terminate the pregnancy) if the ultrasonography indicated a spinal problem, so they felt they did not want this information. Reflective Questions

1. As the nurse, what priority data would you collect from this couple to help define relevant interventions to meet their needs?

2. How can you help this couple if they experience a negative outcome in the birthing suite? What are your personal views on terminating or continuing a pregnancy with a risk of a potential anomaly? What factors may influence your views?

3. With the influence of the recent Human Genome Project and the possibility of predicting open

spinal defects earlier in pregnancy, how will maternity care change in the future?

Name the contributing factors on J.D that might put her at risk to develop iron deficiency anemia.

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Instructions: Response must be at least 510 words written in current APA format with at least two academic references cited. References must be within the last five years.

Hematopoietic:
J.D. is a 37 years old white woman who presents to her gynecologist complaining of a 2-month history of intermenstrual bleeding, menorrhagia, increased urinary frequency, mild incontinence, extreme fatigue, and weakness. Her menstrual period occurs every 28 days and lately there have been 6 days of heavy flow and cramping. She denies abdominal distension, back-ache, and constipation. She has not had her usual energy levels since before her last pregnancy.

Past Medical History (PMH):
Upon reviewing her past medical history, the gynecologist notes that her patient is a G5P5with four pregnancies within four years, the last infant having been delivered vaginally four months ago. All five pregnancies were unremarkable and without delivery complications. All infants were born healthy. Patient history also reveals a 3-year history of osteoarthritis in the left knee, probably the result of sustaining significant trauma to her knee in an MVA when she was 9 years old. When asked what OTC medications she is currently taking for her pain and for how long she has been taking them, she reveals that she started taking ibuprofen, three tablets each day, about 2.5 years ago for her left knee. Due to a slowly progressive increase in pain and a loss of adequate relief with three tablets, she doubled the daily dose of ibuprofen. Upon the recommendation from her nurse practitioner and because long-term ibuprofen use can cause peptic ulcers, she began taking OTC omeprazole on a regular basis to prevent gastrointestinal bleeding. Patient history also reveals a 3-year history of HTN for which she is now being treated with a diuretic and a centrally acting antihypertensive drug. She has had no previous surgeries.

Case Study Questions

  1. Name the contributing factors on J.D that might put her at risk to develop iron deficiency anemia.
  2. Within the case study, describe the reasons why J.D. might be presenting constipation and or dehydration.
  3. Why Vitamin B12 and folic acid are important on the erythropoiesis? What abnormalities their deficiency might cause on the red blood cells?
  4. The gynecologist is suspecting that J.D. might be experiencing iron deficiency anemia.
    In order to support the diagnosis, list and describe the clinical symptoms that J.D. might have positive for Iron deficiency anemia.
  5. If the patient is diagnosed with iron deficiency anemia, what do you expect to find as signs of this type of anemia? List and describe.
  6. Labs results came back for the patient. Hb 10.2 g/dL; Hct 30.8%; Ferritin 9 ng/dL; red blood cells are smaller and paler in color than normal. Research list and describe for appropriate recommendations and treatments for J.D.

Cardiovascular
Mr. W.G. is a 53-year-old white man who began to experience chest discomfort while playing tennis with a friend. At first, he attributed his discomfort to the heat and having had a large breakfast. Gradually, however, discomfort intensified to a crushing sensation in the sternal area and the pain seemed to spread upward into his neck and lower jaw. The nature of the pain did not seem to change with deep breathing. When Mr. G. complained of feeling nauseated and began rubbing his chest, his tennis partner was concerned that his friend was having a heart attack and called 911 on his cell phone. The patient was transported to the ED of the nearest hospital and arrived within 30 minutes of the onset of chest pain. In route to the hospital, the patient was placed on nasal cannula and an IV D5W was started. Mr. G. received aspirin (325 mg po) and 2 mg/IV morphine. He is allergic to meperidine (rash). His pain has eased slightly in the last 15 minutes but is still significant; was 9/10 in severity; now7/10. In the ED, chest pain was not relieved by 3 SL NTG tablets. He denies chills.

Case Study Questions

  1. For patients at risk of developing coronary artery disease and patients diagnosed with acute myocardial infarct, describe the modifiable and non-modifiable risk factors.
  2. What would you expect to see on Mr. W.G. EKG and which findings described on the case are compatible with the acute coronary event?
  3. Having only the opportunity to choose one laboratory test to confirm the acute myocardial infarct, which would be the most specific laboratory test you would choose and why?
  4. How do you explain that Mr. W.G temperature has increased after his Myocardial Infarct, when that can be observed and for how long? Base your answer on the pathophysiology of the event.
  5. Explain to Mr. W.G. why he was experiencing pain during his Myocardial Infarct. Elaborate and support your answer.