NUR 514-Advanced Practice Nursing Assessment DQ 2
NUR 514-Advanced Practice Nursing Assessment DQ 2
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This Assignment will help develop skills to perform an integrated history and physical examination for individuals across the lifespan.
Considerations of lifestyle practices, cultural/ethnic differences, and developmental variations will be incorporated into the plan of care.
Use critical thinking and diagnostic reasoning skills to formulate differential diagnoses, medical diagnoses, and an evidence-based action plan.
Include sections 1 and 2 of the SOAP note with recommendations (incorrect or omitted data) based on feedback provided for the previous sections of the SOAP note.
a. Do not state “Negative, NA or Unremarkable” for any systems because the reader will not know which questions were actually asked by the provider.
2. This is a comprehensive health history and should not contain physical exam findings. The focused history data is relevant to the chief complaint and identified by pertinent positive data documented during the health history.
3. Address each component of the SOAP note as noted in the written guide with relevant data.
4. You may continue with the same volunteer to complete each section of the SOAP note.
II. Life style patterns
0. Immigrant status: Born in San Diego, California. U.S. Citizen
0. Spiritual resources/religion: Christian
0. Health perception: Fair
0. Nutritional patterns: Appetite (any changes); satisfaction with current weight; gains or losses; recall of usual intake; any cultural restrictions/intolerances; amount of fluid per day and type: Healthy appetite, stressed over recent weight gain, eats 3 meals per day and snacks in between meals, patient admits she could benefit from eating healthier, and reduce portions. Patient states she does not drink enough water, her intake is about 48oz of fluids a day that include water, coffee, juices and tea. No cultural restrictions.
0. Elimination patterns: Bowel (usual pattern and characteristics); bladder (usual pattern and characteristics); any incontinence. Daily bowel movement no use of laxatives, polyuria, frequent urination throughout the day, no bedwetting at night, narrowed stream, no incontinence, but sometimes has small void when she sneezes.
0. Living environment: City, state; urban, rural, community; type of dwelling, facilities; known exposures to environmental toxins: Lives in a city, urban community, owns her own home, no known exposure to environmental toxins, other than we she goes downtown and sees buses drive by.
0. Occupational health: Known exposure to environmental toxins at work. No known exposure to toxins at work, her work is a no smoking environment.
ORDER NOW FOR AN ORIGINAL PAPER!!! NUR 514-Advanced Practice Nursing Assessment DQ 2 .
0. Functional assessment: ADLs, IADLs, interpersonal relationships/resources (see page 57 in Jarvis textbook): Patient is 65 y/o and is independent with ADLs, very social, meets with friends to play cards once a week. Patient has a driver’s license in the state of California and drives.
0. Role and family relationships: Immediate family composition; how are family decisions made; impact of family member’s health on family: Patient was married but currently divorced, lives with daughter and teenage grandson, patient independent and makes own decisions regarding health and daily activities, she is also an active member at church, pays her own bills, is very capable of managing every day schedules.
0. Cognitive function: Memory; speech; judgment; senses: Memory appropriate for her age, clear speech pattern.
0. Rest/sleep patterns: Number of hours; naps; number of pillows; any aids for sleep. Sleeps approximately 7 hours at night, does not nap in the day, uses 2 pillows, does not use sleep aids in the form of OTC pills, she does enjoy a hot cup of tea at bedtime that helps her relax.
0. Exercise patterns: Type and frequency: Enjoys walks in the park, walks 3 days out of 7 days.
0. Hobbies/recreation: Leisure activities; any travel outside of the US: Enjoys playing cards, and watching movies when possible, has not traveled recently out of the USA but has traveled in the past to Colombia, South America.
0. Social habits: Tobacco; alcohol; street drug use: Does not drink socially or smoke cigarettes, has never experienced street drugs.
0. Intimate partner violence (review screening questions on page 58 in the Jarvis textbook): Not a victim of domestic violence, patient is currently divorced and does not have an intimate partner.
0. Coping/stress management: Any major life changes in past 2 years; do you feel tense; source; what helps: No major changes in the past 2 years, her divorce was 10 years ago, patient states at first it was hard to adapt but has coped well over the years and feels emotionally healthy. At moments of tension, patient enjoys relaxing over a nice walk in the park. Advanced Practice Nursing Assessment DQ 2
0. Sexual patterns: Are you sexually active; gender preference; has anything changed about your sexual health/function: Currently not sexually active, of heterosexual orientation, major changes in her sexual health has been abstinence since her divorce which she feels comfortable with, patient states that in this stage of life she prefers to be alone and enjoy her family.
III. Review of Symptoms
Symptoms to Inquire About
(please see page 54–56 in Jarvis textbook)
Document pertinent negatives and/or positives
The first system is addressed to provide a guide
General
Wgt Δ; weakness; fatigue; fevers
Pertinent negatives: No weight gain or losses; no weaknesses, fatigue, or fevers
Pertinent positives: Positive weight gain over past 2 months with fatigue and weakness; no fevers Advanced Practice Nursing Assessment DQ 2