Download and analyze the  case study for this week. Create a SOAP note for disease prevention, health promotion, and acute care of the patient in the clinical case. Your care plan should be based on c Nursing Assignment Help

Download and analyze the  case study for this week. Create a SOAP note for disease prevention, health promotion, and acute care of the patient in the clinical case. Your care plan should be based on current evidence and nursing standards of care.

Visit the online library and research 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, 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.

Download the  access codes.

Download the SOAP template to help you design a holistic patient care plan. Utilize the SOAP guidelines to assist you in creating your SOAP note and building your plan of care. You are expected to develop a comprehensive SOAP note based on the given assessment, diagnosis, and advanced nursing interventions. Reflect on what you have learned about care plans through independent research and peer discussions and incorporate the knowledge that you have gained into your patient’s care plan.  If the information is not in the provided scenario please consider it normal for SOAP note purposes, if it is abnormal please utilize what you know about the disease process and write what you would expect in the subjective and objective areas of your note.

Expert Solution Preview

In response to the given content, as a medical professor, I would like to emphasize the importance of creating a comprehensive SOAP note for disease prevention, health promotion, and acute care of the patient in the clinical case. The SOAP note is a vital tool in the healthcare field as it allows healthcare professionals to organize and communicate patient information effectively.

To start, the SOAP note should include subjective information obtained from the patient, such as their chief complaint, medical history, and pertinent symptoms. This provides insight into the patient’s perspective and helps guide the care plan.

Next, the objective information should be documented. This includes physical assessments, vital signs, laboratory results, and any additional diagnostic information. It is important to include specific measurements and data to support the plan of care.

The assessment section of the SOAP note involves the healthcare professional’s clinical judgment based on the subjective and objective information. This is where the healthcare professional can diagnose the patient’s condition and identify any risk factors or areas for health promotion.

Finally, the plan of care should be developed based on current evidence and nursing standards of care. This may include interventions for disease prevention, health promotion, and acute care. It is essential to include specific rationales for each intervention, providing a scientific basis for the chosen actions. Research from reputable sources, such as the online library and government sites like the CDC, WHO, AHRQ, and Healthy People 2020, should be utilized to support the nursing actions in the plan of care.

In addition to the SOAP note, ICD-10 classification should be determined. This classification system is used to assign codes to health conditions and related information. It is crucial to accurately code the patient’s condition for proper documentation and communication between healthcare providers.

In summary, creating a comprehensive SOAP note based on the given clinical case requires incorporating subjective and objective information, making sound assessments, and developing a plan of care supported by current evidence and nursing standards. Proper utilization of the SOAP template and inclusion of detailed scientific rationale is essential to provide quality care to the patient.

Share This Post

Email
WhatsApp
Facebook
Twitter
LinkedIn
Pinterest
Reddit

Order a Similar Paper and get 15% Discount on your First Order

Related Questions

Scenario Upper management has been watching and is impressed Nursing Assignment Help

Scenario Upper management has been watching and is impressed by the work you have done as project lead to gather information for this departmental expansion project. Your administrator passes along their request that you use your skills in project management to explain health care facility design project management by creating a proposal of what this project

IHP 630 Module Four Project Preparation Guidelines and Nursing Assignment Help

IHP 630 Module Four Project Preparation Guidelines and RubricOverview In this module, you learned about how governmental and nongovernmental health insurance models impact financial management and strategic planning in a healthcare organization. You also explored the reporting requirements for payers. In this activity, you will create a report that compares

Topic: The use of Gabapentin for post herpetic neuralgia. Nursing Assignment Help

Topic: The use of Gabapentin for post herpetic neuralgia. Modality:Topical Literature review / Educational practicum for patient’s education. Reference: Multimedia product, video, blog, website, animation ( Topic: The use of Gabapentin for post herpetic neuralgia. Modality:  Literature review / Educational practicum for patient’s education. Reference: Multimedia product, video, blog, website,

Can someone help with …. Briefly discuss the Nursing Assignment Help

Can someone help with …. Briefly discuss the interrelationship among theory, practice, and research. Then, explain how your future practice as a nurse practitioner can inform theory and research.   With at least 500 words, formatted and cited in current APA style with support from at least two academic sources. 

Create a 10-15 slide Power Point presentation of your Nursing Assignment Help

Create a 10-15 slide Power Point presentation of your evidence-based intervention and change proposal to be disseminated to an interprofessional audience of leaders and stakeholders. Include the intervention, evidence-based literature, objectives, resources needed, anticipated measurable outcomes, and how the intervention would be evaluated. Submit the presentation in the digital classroom

CONTROVERSY ASSOCIATED WITH PERSONALITY AND PARAPHILIC Nursing Assignment Help

CONTROVERSY ASSOCIATED WITH PERSONALITY AND PARAPHILIC DISORDERS Between 10% and 20% of the population experience personality disorders. They are difficult to treat as individuals with personality disorders are less likely to seek help than individuals with other mental health disorders. Treatment can be challenging as they do not see their