Nursing

week 5 Patient’s Spiritual Needs: Case Analysis In addition to the topic study materials, use the chart you completed and questions you answered in the Topic 3 about “Case Study: Healing and Autonomy” as the basis for your responses in this assignment. Answer the following questions about a patient’s spiritual needs in light of the […]

Reflection Note and Follow-Up What I will do differently on a similar patient evaluation is that I will check the patient hemoglobin A1C to rule out diabetic origin of the condition . I would send the patient home to try the recommended home remedies for few days and come back for antibiotic treatment since bacterial

Health Promotion: Patient will be educated to wipe from front to back instead of back to front to void contaminating the vagina with bacterial from the rectum. Also, patient will be educated to keep her vulva clean and dry. In addition, patient will be educated to refrain from using agents that are irritating in her

Diagnostic plan: Oligonucleotide probes test will be ordered and send out to outside diagnostic lab company. Wet mount test, KOH/whiff test, and litmus test for pH were all ordered and tested. Results: positive. Treatment and Management: Bacterial vaginosis resolved spontaneously for most women, but the patient has been having the symptoms for one week. I

Subjective Documentation in Provider Notes Subjective narrative documentation in Provider Notes is detailed and organized and includes: Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS) ROS: covers all body systems that may help you formulate a list of differential diagnoses. You should list each

Vaginal Candidiasis: Commonly known as yeast infection. The infection is caused by fungus candida, which causes extreme itching, swelling, and irritation. Symptoms include rash, vaginal discharge that is usually thick, white, and odorless; itching, burning, pain during sex, soreness, and burning. Vaginal candidiasis is ruled out as the primary diagnosis because of the difference in

General–Pt appears diaphoretic and anxious Cardiovascular–PMI is in the 5th inter-costal space at the mid clavicular line. A grade 2/6 systolic decrescendo murmur is heard best at the second right inter-costal space which radiates to the neck. A third heard sound is heard at the apex. No fourth heart sound or rub are heard. No

Episodic/Focused SOAP Note Exemplar Focused SOAP Note for a patient with chest pain S. CC: “Chest pain”  HPI: The patient is a 65 year old AA male who developed sudden onset of chest pain, which began early this morning.  The pain is described as “crushing” and is rated nine out of 10 in terms of intensity. The

Cardiovascular: Denies chest pain or chest discomfort Objective Mr. Rivera is pleasant and cooperative fatgued appearing young boy seated upright on the examination table. He is in no acute distress. He is alert. His speech is clear and coherent. He maintains eye contact throught the interview and examination. He offers information freely and without contradiction.

Home medications: Daily vitamin, over the counter antitussive medication Past medical History: Frequent ear infections as small child. Patient reports last known ear infection was when he was two years old. He reports having pneumonia last that caused him to miss two weeks of school. Social History: Patient lives in a house with parents and