• You should respond to your peers by extending, refuting/correcting, or adding additional nuance to their posts.
• All replies must be constructive and use literature where possible.

Andree Daphnee Renaud.

Focused SOAP Note with Positive and Pertinent Data Only for a 40 Year-Old Female with Endometriosis

Case 3

Patient Information:

Initials: C.P. Age: 40 years old Gender: Female Race: Caucasian

Subjective:

CC (chief complaint): “I have been having severe abdominal pains and cramps, which have become worse when having sexual intercourse for the last two months. During the same time, my

periods have also become considerably heavier.”

HPI: The patient is a 40 year-old Caucasian female who states that the symptoms started two months ago. The pain is located in the lower abdomen and is intermittent. The pain is sharp,

crampy, and becomes worse during menstruation and sex. It is slightly relieved by taking acetaminophen, but comes at any time of the day. The patient rates the pain at 7/10.

Current Medications: Acetaminophen 1 g as needed for pain.

PMHx: Admits to previous admission to the hospital for pneumonia.

Sc Hx: Stays with her husband of fifteen years and two teenage sons. She enjoys cooking, traveling, and hiking. Patient C.P. works as a billing clerk in a local hospital and lives in a middle class

housing complex with all necessary amenities. She only drinks over the weekends when she goes out with her husband.

Family Hx: There is a history of coronary artery disease on her paternal side and type II diabetes mellitus on the maternal side.

ROS:

• GENERAL: She admits to chronic fatigue, chills, occasional fever, and some weight loss.
• GASTROINTESTINAL: Positive for nausea, vomiting, severe abdominal cramps, and painful bowel movements during menstruation.
• GENITOURINARY: Positive for pelvic pain and painful urination at the time of menses.
• MUSCULOSKELETAL: positive for debilitating abdominal cramps.
• HEMATOLOGIC: Heavy menstrual bleeding.

Objective:

Physical Examination

There is severe discomfort and pain during pelvic examination.

Diagnostic Results: Full blood count (WBC 12.0 x 109/L; Hb 11.2 gdl-1), magnetic resonance imaging or MRI (positive for endometriosis in the bladder, ovaries, and Fallopian tubes).

Assessment:

Differential Diagnoses

1. Endometriosis (N80.9): The patient displays classic symptoms of endometriosis, which include abdominal cramps and pain, nausea and vomiting, heavy and prolonged menses, pain during intercourse, fatigue, painful micturition, and changed bowel habits (Hammer & McPhee, 2018). The pathophysiology of endometriosis involves growth of endometrial tissue in areas other than the uterine endometrium.
2. Chlamydia (A74.9): This is a sexually transmitted infection (STI) that is also a possibility in this case. However, it is unlikely as it usually causes a yellowish or greenish abnormal vaginal discharge (Hammer & McPhee, 2018; Jameson et al., 2018). This is absent in this case.
3. Pelvic inflammatory disease or PID (N73.9): This is infection and inflammation of female pelvic structures including the Fallopian tubes and the uterus. It characteristically also causes lower abdominal pain (Hammer & McPhee, 2018; Jameson et al., 2018).

Plan:

• Ibuprofen 400 mg as needed
• Laparoscopic surgery to remove all endometrial tissue
• Warm baths
• Acupuncture
• Health education: Join a support group of women who have had or are having endometriosis. This will help with psychological coping.

References

Hammer, D.G., & McPhee, S.J. (Eds). (2018). Pathophysiology of disease: An introduction

to clinical medicine, 8th ed. McGraw-Hill Education.

Jameson, J.L., Fauci, A.S., Kasper, D.L., Hauser, S.L., Longo, D.L., & Loscalzo, J. (Eds)

(2018). Harrison’s principles of internal medicine, 20th ed. McGraw-Hill Education.

Source: Pri-Med Online CME

https://www.pri-med.com/online-education/webcast/west-2019-opioids-ing/activity

1. Go to https://www.pri-med.com. This is the website for Pri-Med Online CME.

2. Log in and/or Create an account.

3. Click on the Search icon and search for

“Effective and Safe Opioid Use”.

View the Pri-Med training on Effective and Safe Opioid Use. Answer the following questions:

1. Briefly explain how the opioid crisis started and the role of prescription opioids in this crisis.
2. Describe government and healthcare initiatives to decrease opioid prescriptions.
3. Discuss one risk mitigation strategy regarding opioid prescriptions.

• A description of your field education experience, including your agency, the types of social services offered, and the population groups or clientele your agency serves
• An explanation of how engagement occurs in your field education experience

What do you see as the pros and cons of a unionized environment in a health care facility? How can the right to collective bargaining by employees and the mandate to provide care to patients be reconciled?

Legal and Ethical Issues for Health Professionals

Need help with my Nursing question – I’m studying for my class.

Identify your own level of preparedness should disaster strike in your area. Visit the Red Cross site: http://www.redcross.org/get-help/prepare-for-emergencies/be-red-cross-ready to review details on disaster preparedness kit, plan and information. Discuss your response to this information. Were you surprised at your level of readiness? What steps will you take to prepare yourself and your family for the possibility of disaster? How can you share this information with your community in Houston, Texas?

Disasters occur every day. The community health nurse has a significant role in preparedness, response and recovery when disaster strikes locally. Effective response to disaster demands the community health nurse to develop specific competencies. These include understanding the role, recognition of disaster-related health conditions, infection control post disaster, disease reporting, public education and stress management in the affected community.

 Learning Materials

• Clark, M. J. (2015). Population and community health nursing (6th ed.). Boston, MA: Pearson Chapter 25

Assigned websites:

• American Red Cross. (2020). How to prepare for emergencies. 

Discussion: Building a Health History

Effective communication is vital to constructing an accurate and detailed patient history. A patient’s health or illness is influenced by many factors, including age, gender, ethnicity, and environmental setting. As an advanced practice nurse, you must be aware of these factors and tailor your communication techniques accordingly. Doing so will not only help you establish rapport with your patients, but it will also enable you to more effectively gather the information needed to assess your patients’ health risks.

For this Discussion, you will take on the role of a clinician who is building a health history for a particular new patient assigned by your Instructor.

Photo Credit: Sam Edwards / Caiaimage / Getty Images

To prepare:

With the information presented in Chapter 1 of Ball et al. in mind, consider the following:

• By Day 1 of this week, you will be assigned a new patient profile by your Instructor for this Discussion. Note: Please see the “Course Announcements” section of the classroom for your new patient profile assignment.
• How would your communication and interview techniques for building a health history differ with each patient?
• How might you target your questions for building a health history based on the patient’s social determinants of health?
• What risk assessment instruments would be appropriate to use with each patient, or what questions would you ask each patient to assess his or her health risks?
• Identify any potential health-related risks based upon the patient’s age, gender, ethnicity, or environmental setting that should be taken into consideration.
• Select one of the risk assessment instruments presented in Chapter 1 or Chapter 5 of the Seidel’s Guide to Physical Examination text, or another tool with which you are familiar, related to your selected patient.
• Develop at least five targeted questions you would ask your selected patient to assess his or her health risks and begin building a health history.

By Day 3 of Week 1

Post a summary of the interview and a description of the communication techniques you would use with your assigned patient. Explain why you would use these techniques. Identify the risk assessment instrument you selected, and justify why it would be applicable to the selected patient. Provide at least five targeted questions you would ask the patient. 

THE CASE STUDY 

Group 2: 76-year-old black male with disabilities living in an urban setting

Write a 750-1,000 word paper in which you review public policy and how it affects employment. Address the following scenarios:

Scenario 1: Nurse Deb was due for her annual flu vaccination as mandated by her hospital’s policy. Nurse Deb is a big supporter of the antivaccination movement and refused to obtain her annual flu vaccination. Upon notice that nurse Deb did not obtain the vaccination, the nurse manager fired Nurse Deb. Nurse Deb has decide to file a wrongful termination suit. As the director of nursing, how would you handle this situation?

1. What evidence does Nurse Deb have that could help her win the case?
2. What law protects the hospital’s mandated vaccination procedures?
3. How concerned should the hospital be if the lawsuit is a success?
4. If the lawsuit is a success, how does this impact workplace safety and the obligation of the health care facility to provide protection?

Scenario 2: Joe Gomez worked as a plant operations specialist at Premier Hospital. While Joe’s manager was working on the HVAC system that protects patients from harmful viruses and bacteria, he noticed that he was not using OSHA-approved filters. Joe felt that it was important to report this to the compliance officer. The day following his report, Joe was fired by his manager. As the CEO of Premier Hospital, how would you handle the situation?

1. How concerned should you be about the termination of Joe?
2. What legal principles are involved and how do they reinforce workplace safety?
3. If Joe was a member of the local employee services union, does this make the termination different?

Prepare this assignment according to the guidelines found in the APA Style Guide, located in the Student Success Center.

This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.

Legal and Ethical Issues for Health Professionals

Pozgar, G. D. (2020). Legal and ethical issues for health professionals (5th ed.). Burlington, MA: Jones and Bartlett Learning. ISBN-13: 9781284144185

Movie – The American Nurse

1) Utilize Readings and Resource Video to assist in findings library articles

2) Module 2 Movie Critique Assignment(10 points) 

Assignment: Choose and watch a television show or movie that has nursing as a main focus. The SMSU McFarland library may be a source for a nursing movie. Also, the Truth About Nursing website may be a website to provide some ideas about movies/television shows related to nursing. The website is: Truth About Nursing(look for “Media Watch” in the website headings).

Assignment: Choose and watch a television show or movie that has nursing as a main focus. Critique the movie/show on the basis of the image of nursing presented: 

• How would you describe the professional role of the nurse (educator, clinician, leader, activist, researcher)?
• How would you describe the nursing environment –was it realistic?
• How were the nurses portrayed -intelligent and/or educated?
• How were nurses addressed (language) by other characters?
• Would the nurses meet the standards for most honest and ethical practitioner?
• How would you describe the interprofessional collaboration found in the show or movie?
• What evidence was there of any other societal factors that have the potential to stimulate or squelch interest in nursing as a profession, as discussed in this week’s readings?
• How would you describe any evidence of workplace incivility?
• Did you find patient-centered care provided? –how or how not?

Points for Assignment (Rubric also found in Appendix A in NURS 300 Syllabus):

• 1 point for discussion of the professional role of the nurse in the show or movie.
• 1 point for discussion of the nursing environment, including setting, clothing/uniforms, medical supplies, etc.
• 1 point for discussion of the portrayal of the intelligence of nurses in the show or movie.
• 1 point for discussion regarding how nurses were addressed by others.
• 1 point for discussing if the nurse(s) portrayed in the show/movie would meet the standards for most honest and ethical practitioner.
• 1 point for discussion about any interprofessional collaboration found in the show or movie.
• 1 point for discussion of societal factors that have the potential to stimulate or squelch an interest in nursing.
• 1 point for discussion of any evidence of workplace incivility.
• 1 point for discussion about if patient-centered care was provided? –how or how not?

Scenario:  You, the nurse manager, have been notified that you must downsize your unit staff.  You have also been informed that your role as nurse manager will be expanded to cover more client areas, and that the staff for each shift on your current unite will be reassigned.  How can you prepare yourself and your staff for these changes?

Compose a tentative plan for addressing the downsizing and staff relocation with rationales.  (Consider small staff meetings to allow people to talk about the changes.  Also consider your own and your staffs’ adaptability traits.)