NRNP 6552: Advanced Nurse Practice in Reproductive Health Care Episodic/Focused SOAP Note

NRNP 6552: Advanced Nurse Practice in Reproductive Health Care Episodic/Focused SOAP Note

Sample Answer for NRNP 6552: Advanced Nurse Practice in Reproductive Health Care Episodic/Focused SOAP Note Included After Question

Description

Case Study: Urinary Leakage

Mable Albright is a 48-year-old, native American who presents to your clinic with the complaint of urinary leakage. She relates this has been worsening over the past 2 years.  She now must wear a pad all the time and states it is interfering with her work as she is going to the bathroom all the time.  Medical history is negative, surgical history is remarkable for wisdom teeth and a bilateral tubal ligation.

VSS: and normal

5’0 172 lbs. (BMI 33.6) T 98 P 70 R18 02Sat 98%

QUESTIONS:

1. What questions do you have for Mable?

2. What are you considering for her?

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UPDATE:

Mable relates she leaks when she coughs or laughs and sometimes can’t get her pants down before her urine stream starts when she goes to the bathroom.  When she leaks, she states she will soak thru her underwear and pants. Occasionally, the urine will run down her legs.

Mable has had 5 pregnancies she delivered at term. The first was an 8 lb. 10oz delivered by forceps, the next three were spontaneous and they weighed between 6 and 8 and ½ pounds, and her last was a 10 lb. baby for which she had a shoulder dystocia and “tore a lot”.

Mable relates that sometimes after cleaning her house or standing all day, she feels a lot of pressure, but it goes away when she sits down. All her symptoms have been present since her last delivery 9 years ago, but they have been getting worse.

You have Mable complete a voiding diary which shows that she drinks approximately 84 ounces of fluid through the day and voids about every 3-4 hours during the day. Her leaking has occurred when she first gets home from work.

Physical exam:

• VVBSU, parous, vagina somewhat gaping, 1stdegree cystocele

• Cervix parous, wnl

• Uterus: anteverted, 10 cm, non-tender

• Adnexa: without masses or tenderness

Urine culture and urinalysis-PENDING

QUESTION:

What is your differential diagnosis?

Questions for the case study are highlighted below and you are to provide a differential diagnosis (dx) with a minimum of 3 possible conditions or diseases.

Define what you believe is the most important diagnosis any why. Be sure to include the priority in conducting your assessment.

Use the focused SOAP NOTE template and focus on what is being asked of you as highlighted below.  Don’t forget for an episodic visit, there is NOT to be a full PE.  Focus on the systems that correlate to your Chief Complaint.

• Differential diagnosis (dx) with a minimum of 3 possible conditions or diseases.
• Define what you believe is the most important diagnosis. Be sure to include the first priority in conducting your assessment.
• Explain which diagnostic tests and treatment options you would recommend for your patient and explain your reasoning.

NRNP 6552: Advanced Nurse Practice in Reproductive Health Care Episodic/Focused SOAP Note Template Patient Information: Initials, Age, Sex, Race S. CC (chief complaint): This is a brief statement identifying why the patient is here in the patient’s own words, for instance, “headache,” not “bad headache for 3 days.” HPI: This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. Use LOCATES Mnemonic to complete your HPI. You need to start every HPI with age, race, and gender (e.g., 34-year-old African American female). You must include the seven attributes of each principal symptom in paragraph form, not a list. If the CC was “headache,” the LOCATES for the HPI might look like the following example: Location: head Onset: 3 days ago Character: pounding, pressure around the eyes and temples Associated signs and symptoms: nausea, vomiting, photophobia, phonophobia Timing: after being on the computer all day at work Exacerbating/relieving factors: light bothers eyes, Naproxen makes it tolerable but not completely better Severity: 7/10 pain scale Current Medications: Include dosage, frequency, length of time used, and reason for use. Also include over-the-counter (OTC) or homeopathic products. Allergies: Include medication, food, and environmental allergies separately. Provide a description of what the allergy is (e.g., angioedema, anaphylaxis). This will help determine a true reaction versus intolerance. PMHx: Include immunization status (note date of last tetanus for all adults), past major illnesses, and surgeries. Depending on the CC, more info is sometimes needed. © 2022 Walden University, LLC NRNP 6552: Advanced Nurse Practice in Reproductive Health Care Soc & Substance Hx: Include occupation and major hobbies, family status, vaping, tobacco and alcohol use (previous and current use, how many times a day, how many years), and any other pertinent data. Always add some health promotion questions here, such as whether they use seat belts all the time or whether they have working smoke detectors in the house, the condition of the living environment, text/cell phone use while driving, and support systems available. Fam Hx: Illnesses with possible genetic predisposition, contagious illnesses, or chronic illnesses. The reason for death of any deceased first-degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent. Surgical Hx: Prior surgical procedures. Mental Hx: Diagnosis and treatment. Current concerns: (Anxiety and/or depression). History of self-harm practices and/or suicidal or homicidal ideation. Violence Hx: Concern or issues about safety (personal, home, community, sexual— current and historical). Reproductive Hx: Menstrual history (date of last menstrual period [LMP]), pregnant (gravida and Parity), nursing/lactating (yes or no), contraceptive use (method used), types of intercourse (oral, anal, vaginal, other), gender sexual preference, and any sexual concerns. ROS: This covers all body systems that may help you include or rule out a differential diagnosis. You should list each system as follows: General: Head: EENT: and so forth. You should list these in bullet format and document the systems in order from head to toe. Example of Complete ROS: GENERAL: No weight loss, fever, chills, weakness, or fatigue. HEENT: Eyes: No visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat. SKIN: No rash or itching. CARDIOVASCULAR: No chest pain, chest pressure, or chest discomfort. No palpitations or edema. RESPIRATORY: No shortness of breath, cough, or sputum. GASTROINTESTINAL: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood. © 2022 Walden University, LLC NRNP 6552: Advanced Nurse Practice in Reproductive Health Care NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control. MUSCULOSKELETAL: No muscle pain, back pain, joint pain, or stiffness. HEMATOLOGIC: No anemia, bleeding, or bruising. LYMPHATICS: No enlarged nodes. No history of splenectomy. PSYCHIATRIC: No history of depression or anxiety. ENDOCRINOLOGIC: No reports of sweating or cold or heat intolerance. No polyuria or polydipsia. GENITOURINARY/REPRODUCTIVE: Burning on urination. Pregnancy. LMP: MM/DD/YYYY. Breast-lumps, pain, discharge? No reports of vaginal discharge, pain?. sexually active? ALLERGIES: No history of asthma, hives, eczema, or rhinitis. O. Physical exam: From head to toe, include what you see, hear, and feel when conducting your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and history. Do not use “WNL” or “normal.” You must describe what you see. Always document in head-to-toe format (i.e., General: Head: EENT:). Diagnostic results: Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines). A. Primay and Differential Diagnoses (list a minimum of 3 differential diagnoses). Your primary or presumptive diagnosis should be at the top of the list. For each diagnosis, provide supportive documentation with evidence-based guidelines. P. Includes documentation of diagnostic studies that will be obtained, referrals to other health care providers, therapeutic interventions, education, disposition of the patient, and any planned follow-up visits. Each diagnosis or condition documented in the assessment should be addressed in the plan. The details of the plan should follow an orderly manner. Also included in this section is the reflection. The student should reflect on this case and discuss whether or not they agree with their preceptor’s treatment of the patient and why or why not. What did they learn from this case? What would they do differently? © 2022 Walden University, LLC NRNP 6552: Advanced Nurse Practice in Reproductive Health Care Also include in your reflection a discussion related to health promotion and disease prevention, taking into consideration patient factors (e.g., age, ethnic group), PMH, and other risk factors (e.g., socioeconomic, cultural background). References You are required to include at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines that relate to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 7th edition formatting. © 2022 Walden University, LLC

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