Fill in order details

  • Submit your instructions
    to writers for free!

Chat with the writer

  • Chat with preferred expert writers
  • Request a preview of your paper
    from them for free

Editing

  • Project edited by the quality evaluation department

Download Your Completed Project

  • Download the completed project from your account or have it sent to your email address

[ANSWERED] After completing this week’s Practicum Experience, review the Comprehensive SOAP Note Exemplar and Template in this week’s Resources

Practicum Experience – Comprehensive SOAP Note #3 nurs6531

After completing this week’s Practicum Experience, review the Comprehensive SOAP Note Exemplar and Template in this week’s Resources, and reflect on a patient who presented with musculoskeletal disorders or pain. Describe the patient’s personal and medical history, drug therapy and treatments, and follow-up care. Practicum Experience – Comprehensive SOAP Note #3 nurs6531

All SOAP notes must be signed and each page must be initialed by your preceptor. When you submit your SOAP Notes, you should include the complete SOAP Note as a Word document and pdf/images of each page that is initialed and signed by your preceptor. You must submit your SOAP Notes using SAFE ASSIGN.

Please Note: Electronic signatures are not accepted. If both files are not received by the due date, faculty will deduct points per the Walden Late Policies.

By Day 7 of Week 8

This Comprehensive SOAP Note #3 is due. You will submit two files for the Week 8 Comprehensive SOAP Note #3, including a Word document and pdf/images of each page that is initialed and signed by your preceptor by Day 7 of Week 6.

Expert Answer and Explanation

Comprehensive Soap Note

Patient Initials: ___AA____               Age: ___27 years____                                    Gender: _____Male__

Subjective Data 

Chief Complaint:

“My back is paining a lot.”

History of Present Illness:

AA is a 27 African American male who visited a healthcare facility complaining of back pain. The patient noted that he had been feeling the pain for the last four days. The patient noted that he started feeling lower back pain after falling in the bathroom six weeks ago, but the pain became severe four days ago. He reported that he tried taking over-the-counter Tylenol, but the pain has not reduced. The pain can be scaled as 7/10.

Medication: OTC Tylenol.

Allergies: No allergies.

Past Medical History:  He has never been hospitalized. He was treated for pneumonia one year ago.

Past Surgical History: No major surgery.

OB/GYN History: N/A

Personal/Social History: He often drinks alcohol every weekend but does not smoke Immunizations: He received pneumonia vaccine 1 year ago.

Family History: His dad died of a car accident, and his mother died of a heart attack. Review of Systems

General: The patient has fatigue, fever, weight loss, diarrhea, and loss of appetite.

The patient has a fever, fatigue, diarrhea, weight loss, and reduced appetite

HEENT: Healthy head, eyes, ears, nose, and throat.

Musculoskeletal: Back and rectal pain.

Gastrointestinal: Cannot defecate though has the urge to defecate.

Hematologic: Reports bleeding ulcers.

Objective Data

Physical Exam: The patient was seen limping during the physical examination, and his lower back was swollen and tender. His eyes were also swollen.

Vitals: BP 127/82, Temp 39.2 degrees centigrade, Wt 74, Ht 189cm, RR 20, Hr 76.

Assessment

  1. Inflammatory Bowel Disease- This disease is the primary diagnosis for this case. IBD is an infection that causes pain in the lower abdomen (Colombel et al., 2017). This disease is the primary diagnosis because the patient reports most of its symptoms
  2. Colon Cancer-Colon cancer is the cancer that affects the colon. It has been included in diagnosis because it causes abdominal pain.
  3. Bowel Obstruction-This condition has been included in the diagnosis because it also causes abdominal pain by blocking digestion wastes in the intestines.

Plan 

Treatment Plan

 Blood test, stool test, and X-ray were ordered and the patient found to have IBD. The disease can be treated using three types of drugs, including painkillers, anti-inflammatory medications, and antibiotics. The patient should be recommended Dipentum 1.0 g/day twice a day for ten days (Sakur et al., 2019). Dipentum is a medication used to treat inflammation. To relieve his pain, the nurse should recommend diclofenac sodium Voltaren 18 mg orally thrice a day for four days (Rosen et al., 2017). The patient should be recommended Cipro 500 mg orally twice a day from 4 weeks to fight infection.

Follow-Up Care

The first follow up care for this patient is a checkup (Brandenbarg et al., 2017). The patient should be told to visit the hospital two weeks after being discharged so that the nurse can check and see how the patient is fairing. The nurse can also implement follow up care by calling the patient often to find out how he is doing.

Reflection

From this soap note, I have leaned that nurses should conduct proper diagnosis on their patients before recommending any medication. I have also learned that nurses should plan follow-up care programs to ensure that patients respond well to medication.

References

Brandenbarg, D., Berendsen, A. J., & de Bock, G. H. (2017). Patients’ expectations and preferences regarding cancer follow-up care. Maturitas, 105, 58-63. https://doi.org/10.1016/j.maturitas.2017.07.001

Colombel, J. F., Sands, B. E., Rutgeerts, P., Sandborn, W., Danese, S., D’Haens, G., … & Parikh, A. (2017). The safety of vedolizumab for ulcerative colitis and Crohn’s disease. Gut, 66(5), 839-851. http://dx.doi.org/10.1136/gutjnl-2015-311079

Rosen, M. J., Karns, R., Vallance, J. E., Bezold, R., Waddell, A., Collins, M. H., … & Baker, S. S. (2017). Mucosal expression of type 2 and type 17 immune response genes distinguishes ulcerative colitis from colon-only Crohn’s disease in treatment-naive pediatric patients. Gastroenterology, 152(6), 1345-1357. https://doi.org/10.1053/j.gastro.2017.01.016

Sakur, A. A., Dabbeet, H. A., & Noureldin, I. (2019). Novel Drug Selective Sensors for Simultaneous Potentiometric Determination of both Ciprofloxacin and Metronidazole in Pure form and Pharmaceutical Formulations. Research Journal of Pharmacy and Technology, 12(7), 3377-3384. DOI : 10.5958/0974-360X.2019.00570.5

Place your order now for the similar assignment and get fast, cheap and best quality work written by our expert level  assignment writers.After completing this week’s Practicum Experience, review the Comprehensive SOAP Note Exemplar and Template in this week’s Resources

Use Coupon Code: NEW30 to Get 30% OFF Your First Order

ANSWERED! 67-year-old female presents with chief complaint

SOLVED! Healthcare continues to be a lucrative target for

SOLVED! Post a brief explanation of the differences between

SOLVED!! Explain how interprofessional collaboration will

SOLVED! Mr. EBR is a 74-year-old retired Hispanic gentleman

ANSWERED!! Identify your role as a health care professional in supporting Abby’s or Shanti’s dying rituals

ANSWERED!! Explain how personal and business ethics can be subconsciously overridden in decision-making. Does your selected business exemplify this?

ANSWERED!! What parts of the lawmaking process does a nurse have an opportunity to influence the final bill passage?

[ANSWERED] Pakistani Woman with Delusional Thought Processes

[ANSWERED] Create your own script for building a health history and use the Health History Template for guidance (consider the type of language you would use to help your patient be more comfortable).

[ANSWERED] Assessing the Genitalia and Rectum

[ANSWERED] Explain how you would advocate for the

What our customers say
_____

  • Essay was good; although need to do few amendments and add few things, overall it was good and justify money paid.

     

    FinanceProfessional assignment help services
  • it was good
    it has introduction, body paragraphs, and conclusion as well
    it was really helpful

    PsychologyProfessional assignment help services
  • Great service. Always provide quick response and best online support and have very very less plagiarism.

    EconomicsProfessional assignment help services
  • Thanks for giving my assignment on time. I really appreciated the work done. This keeps me submitting new assignments.

    HealthcareProfessional assignment help services
  • Thank you my writer. Good job and I really enjoy you fast response. I definitely will recommend to my friends.

     

    NursingProfessional assignment help services
  • Thanks for giving my assignment on time. I really appreciated the work done. This keeps me submitting new assignments.

    NursingProfessional assignment help services
  • Great service. Always povide quick response and best online support and have very very less plagiarism.

     

    Business LawProfessional assignment help services
  • Good writer that fulfil all the requirements that i have been told to the writer. The writer even called to discuss everything with me to continue my assighnment

     

    FinanceProfessional assignment help services
  • Great work on time delivered for work, good understanding well prepared. References was well written in APA format

    NursingProfessional assignment help services
  • The writer had clear communication and ensured to give me a brief overview of how my assignment was going to be structured including an average of the words used in each section in order to avoid going over the limit. Didn't need to escalate even once because the quality of the work was in line with the Standard quality that I chose.

    AccountingProfessional assignment help services
  • It was okay. Not bad, could do better! But marks were good, feedback was also good, so overall 4/5

     

    ProgrammingProfessional assignment help services
  • The solution was excellent and all the requirements was taken into consideration.

    ChemistryProfessional assignment help services
  • On time and the assisgment is veryy well done. thank you very much. i'm happy and this is not the last time of me getting help

     

    ManagementProfessional assignment help services
  • This is solid work thankyou for all the help with this PowerPoint; I m curious what grade ill get in it

     

    NursingProfessional assignment help services
  • Great Work Completed in under a Hour thank you so much. I got a 100 percent on my assignment.

    NursingProfessional assignment help services
  • I got 87%. Thanks for that. I am quite satisfied as You reviewed and changed when I ask for some changes.

     

    ChemistryProfessional assignment help services
  • I got a Distinction in this course. Highly satisfied with the expert work and effort.

     

    Business LawProfessional assignment help services
  • I am very happy with this assignment. Thank you very much to the expert who has done this for me.

     

    Business LawProfessional assignment help services
  • So far this is the highest marks I got for an assignment done by you guys. I got 42/50 for this assignment. The exact feedback from my lecturer was:
    Introduction: Good introduction to assisted dying, especially in relation to laws within Australia. Introduction was a little too long.
    Aim or Purpose: Good purpose but improved grammar needed. Good use of PICO.
    Method: The method, while explained is very out of order. Try to write a methods section that can be followed in a step by step fashion

    NursingProfessional assignment help services
  • You did a good job just some details were missed enough attention. To be honest, you did much better job than the other websites. I would like to have more experience with you then I can give you more detailed feedback.

     

    ManagementProfessional assignment help services

You cannot copy content of this page