Patient Setting:
28 year old female presents to the clinic with a 2 days history of frequency, burning and pain upon urination; increase lower abdominal pain and vaginal discharge over the past week.
HPI
Complains of urinary symptoms similar to those of previous urinary tract infections (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 year); gonorheax2; chlamydia X1; Gravida IV Para III.
Past Surgical History
Tubal Ligation 2 years ago.
Family/ Social History
Family: Single; history of multiple sexual partners; currently leaves with new boyfriend and two children.
Social: Denies smoking, alcohol and drug abuse.
Medication History
None
Trimethoprim (TOM) Sulfamethoxazole (SMX) rash.
NKAD
ROS
Last pap 6 months ago, Denies breast discharge. Positive for urine to look 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: Regular rate and rhythm normal S1 and S2.
Chest: WNL.
Abd: soft, tender, increase suprapubic tenderness.
GU: Cervical motion tenderness, adnexal tenderness, foul smelling vaginal drainage.
Rectal: WNL.
EXT: WNL.
NEURO: WNL.
Laboratory and Diagnostic Testing
Lkc differential: Neutraphils 68%, Bands 7%, Lymphs 7%, Monos 8%, EOS 2 %
UA: Starw colored. Sp gr 1.015, Ph 8.0, Protein neg, Glucose neg, Ketone neg, Bacteria- many Lcks 10-15, RBC 0-1
Urine gram stain- Gram negatives rods
Vaginal discharge culture: Gram negative diplococci, Neisseria gonorrhoeae, sensitivities pending
Positive monoclonal AB for Chlamydia, KOH preparation, Wet preparation and VDRL negative
Pleased fallow this instructions.
This is the criteria my instructor will use to grade me.
With this case study analyze and create a comprehensive plan of care for acute/chronic care, disease prevention, and health promotion for this patient and disorder for the patient in the clinical case. The care plan should be based on current best practices and supported with citations from current literature, such as systematic reviews, published practice guidelines, standards of care from specialty organizations, and other research based resources. In addition, you will provide a detailed scientific rationale that justifies the inclusion of this evidence in your plan. Your paper should adhere to APA format for title page, headings, citations, and references. The paper should be no more than 3 pages typed excluding title page and references.
Provide at least 3 differentials medical diagnosis and a plan of car for each.
Provide Journals and research articles 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, and 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.
SOAP note
Evaluation of priority diagnosis
Facilitators and barriers to disorder management
Assignment Grading Criteria
Introduction
The submission included a general introduction to the priority diagnosis.
Subjective Data
The submission included the patient’s interpretation of current medical problem. It included chief complaint, history of present illness, current medications and reason prescribed, past medical history, family history, and review of systems.
Objective Data
The submission included the measurements and observations obtained by the nurse practitioner. It included head to toe physical examination as well as laboratory and diagnostic testing results.
Assessment
The submission included at least three priority diagnoses. Each diagnosis was supported by documentation in subjective and objective notes and free of essential omissions. All diagnoses were documented using acceptable terminologies and current ICD-10 codes.
Plan of Care
Plan included diagnostic and therapeutic (pharmacologic and non-pharmacologic) management as well as education and counseling provided. The plan was supported by evidence/guidelines, and the follow-up plans were noted.
Evaluation of Priority Diagnosis
The plan chose the priority diagnosis for the patient and differentiated the disorder from normal development. Discussed the physical and psychological demands the disorder places on the patient and family and key concepts to discuss with them. Identified key interdisciplinary team personnel needed and how this team will provide care to achieve optimal disorder management and outcomes.
Facilitators and Barriers
The submission interpreted facilitators and barriers to optimal disorder management and outcomes and strategies to overcome the identified barriers.
Conclusion
The submission included what should be taken away from this assignment.
APA/Style/Format
The submission was free of grammatical, spelling, or punctuation errors. Citations and references were written in correct APA Style.
Utilized proper format with coversheet, header.
This is the care plan template you need to fill it out base on the patient information on the case study.
Provided below. Please try to reword the information, do not use the exact words to fill out the
**Please delete this statement and anything in italics prior to submission to shorten the length of your paper.
Care Plan Template
Patient Initials: J.J
Subjective Data: (Information the patient tells you regarding themselves: Biased Information):
Chief Compliant: (In patient’s exact words)
History of Present Illness: (Analysis of current problems in chronologic order using symptom analysis [onset, location, frequency, quality, quantity, aggravating/alleviating factors, associated symptoms and treatments tried]).
PMH/Medical/Surgical History: (Includes medications and why taking, allergies, other major medical problems, immunizations, injuries, hospitalizations, surgeries, psychiatric history, obstetric and history sexual history).
Significant Family History: (Includes family members and specific inheritable diseases).
Social History: (Includes home living situation, marital history, cultural background, health habits, lifestyle/recreation, religious practices, educational background, occupational history, financial security and family history of violence).
Review of Symptoms: (Review each body system – This section you should place POSITIVE for… information in the beginning then state Denies…). – General:; Integumentary:; Head:; Eyes: ; ENT:; Cardiovascular:; Respiratory: ; Gastrointestinal:; Genitourinary:; Musculoskeletal:; Neurological:; Endocrine:; Hematologic:; Psychologic: .
Objective Data:
Vital Signs: BP – ; P ; R ; T ; Wt. ; Ht. ; BMI .
Physical Assessment Findings: (Includes full head to toe review)
HEENT:
Lymph Nodes:
Carotids:
Lungs:
Heart:
Abdomen:
Genital/Pelvic:
Rectum:
Extremities/Pulses:
Neurologic:
Laboratory and Diagnostic Test Results: (Include result and interpretation.)
Assessment: (Include at least 3 priority diagnosis with ICD-10 codes. Please place in order of priority.)
Plan of Care: (Addressing each dx with diagnostic and therapeutic management as well as education and counseling provided).
