Posted: October 6th, 2022

Advanced Practice Nursing Assessment DQ 2

DQ 2 Advanced Practice Nursing

This Assignment will Help improve abilities in performing a comprehensive history and physical examination.

The plan of care will take into account lifestyle choices, cultural and ethnic disparities, and developmental distinctions.

Formulate differential diagnoses, medical diagnoses, and an evidence-based action plan.

Part 1 and 2 of the SOAP note should be revised based on previous sections’ input (incorrect or omitted data).

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No “Negative, NA, or Unremarkable” for any systems because the reader won’t know which questions the provider asked.

A physical exam should not be included in this full health history. The focused historical data is identified by relevant positive data gathered during the health history.

3. Fill in each component of the SOAP note as outlined in the published guide.

4. Use the same volunteer to complete the SOAP note.

II. Life style

Born in San Diego, California. Amerikan

Christian spirituality/religion

Fair health perception

Food intake: recollection of normal intake; cultural restrictions/intolerances; appetite (changes); satisfaction with present weight; gains or losses; daily fluid intake and type: Patient admits she may benefit from eating healthier and reducing quantities. Her daily fluid intake is approximately 48oz of water, coffee, juices, and tea. No cultural barriers.

0. Elimination patterns: bowel; bladder; incontinence. No bedwetting at night, narrowed stream, no incontinence, but has little void when she sneezes.

Environmental contaminants known to have been exposed to: Has no known exposure to environmental contaminants, other than when she visits downtown and sees buses pass by.

0. Occupational health: Toxin exposure at work. Her workplace is nonsmoking, thus no known exposure to contaminants.

(See page 57 of Jarvis textbook): It’s a 65 year old woman who is quite social and plays cards once a week with pals. Patient possesses a California driver’s license and drives.

Family composition; how decisions are made; impact of member’s health on family: Patient is divorced, lives with daughter and adolescent grandson, is self-sufficient, makes her own health and everyday decisions, attends church regularly, pays her own bills, and can manage her own schedule.

0. Memory, speech, judgment, and senses: Age-appropriate memory, clear speaking pattern.

0. Sleeping habits: hours, naps, pillows, and other help. She sleeps for about 7 hours at night, doesn’t nap during the day, uses 2 pillows, and doesn’t take OTC sleep aids, although a hot cup of tea before bed helps her relax.

0 Exercise routines: What, how often? Walks in the park 3 days a week.

0. Hobbies/recreation: Travel beyond the US: Has not gone recently outside of the USA but has previously visited Colombia, South America.

0 Social Norms No social drinking or smoking, no experience with street narcotics.

0. Intimate partner violence (page 58 of the Jarvis textbook): Patient is divorced and does not have an intimate relationship.

How are you coping/managing stress? Have you made major life changes in the last 2 years? Her divorce happened 10 years ago, and she says she found it difficult at first, but she has adjusted well and is emotionally healthy. During stressful times, patient loves a stroll in the park. DQ 2 Advanced Practice Nursing

0 Sexual traits Are you sexually active? Has your sexual health/function changed? Her sexual health has changed significantly since her divorce, which she is content with. She claims that at this time of her life she likes to be alone and enjoy her family.

III. Symptom Review

Ask About Symptoms

(See Jarvis textbook pages 54–56)

Note any downsides or positives.

The first system is a guide.

General

Wgt; tiredness; fevers

No weight gain or loss; no weakness, exhaustion, or fevers

Positive weight increase in 2 months with weariness and lethargy; no fevers DQ 2 Advanced Practice Nursing
Advanced Practice Nursing Assessment DQ 2

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.

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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.

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

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