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Tag: Nursing

  • [Solved] Abortion Forum

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    Based on your assigned readings and lecture materials this week, engage with your peers and me by initiating a thread or responding to another peer's thread or one of my threads. You should post a minimum of three times. – Is there something you are learning this week that you are excited about? – C…

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    Assignment Prompt & Instructions

    Based on your assigned readings and lecture materials this week, engage with your peers and me by initiating a thread or responding to another peer's thread or one of my threads. You should post a minimum of three times.

    – Is there something you are learning this week that you are excited about?
    – Can you apply any of the concepts this week to the career you are interested in pursuing?
    – Do you have any questions about the concepts you are learning this week?

    – You are not required to initiate a thread, however, everyone must post at least once by 11:59 PM ET Thursday. There is no minimum or maximum word count. You will be graded on the relevance of your post to the topic and the application of the concepts.
    – When responding to your peers, you should extend, refute/correct, or add additional nuance to their posts.
    – All replies must be constructive and follow proper netiquette. [Click here to go to the Academic Continuity Guide for Students and read the Course Communication Guidelines (Netiquette)Links to an external site.](https://www.stu.edu/academic-continuity-guide-for-students/).

    – 2 years ago

  • [Solved] Abortion fo

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    Based on your assigned readings and lecture materials this week, engage with your peers and me by initiating a thread or responding to another peer's thread or one of my threads. You should post a minimum of three times. – Is there something you are learning this week that you are excited about? – C…

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    Assignment Prompt & Instructions

    Based on your assigned readings and lecture materials this week, engage with your peers and me by initiating a thread or responding to another peer's thread or one of my threads. You should post a minimum of three times.

    – Is there something you are learning this week that you are excited about?
    – Can you apply any of the concepts this week to the career you are interested in pursuing?
    – Do you have any questions about the concepts you are learning this week?
    – You are not required to initiate a thread, however, everyone must post at least once by 11:59 PM ET Thursday. There is no minimum or maximum word count. You will be graded on the relevance of your post to the topic and the application of the concepts.
    – When responding to your peers, you should extend, refute/correct, or add additional nuance to their posts.
    – All replies must be constructive and follow proper netiquette. [Click here to go to the Academic Continuity Guide for Students and read the Course Communication Guidelines (Netiquette)Links to an external site.](https://www.stu.edu/academic-continuity-guide-for-students/).

    – 2 years ago

  • [Solved] Discussion 2 OB

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    – Focusing on women's health: – Name and describe the components and rationale of the gynecological health history. – Define and describe each component of the GTPAL system used to document pregnancy history. – Following the guidelines of the United States Preventive Service Taskforce (USPSTF) what …

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    Assignment Prompt & Instructions

    – Focusing on women's health:
    – Name and describe the components and rationale of the gynecological health history.
    – Define and describe each component of the GTPAL system used to document pregnancy history.
    – Following the guidelines of the United States Preventive Service Taskforce (USPSTF) what screening recommendations would you do to G.R. a 66-year-old female patient who visits you at the office for the first time (last visit to her PCP 5 years ago) with only positive health history of hysterectomy 10 years ago due to fibroids.
    – A 35-year-old women with a BMI of 40 comes in asking about combined hormonal contraception’s. You explain the contraindications for hormonal contraception include (name more than 4 contraindications).

    **Submission Instructions:**

    – Include at least two references in your post. WITHIN 5 YEARS 2020-2025
    – Your initial post should be at least 500 words, formatted and cited in current APA style with support from at least 2 academic sources. Your initial post is worth 8 points.

    – 2 years ago

  • [Solved] GLOBAL W3

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    Investigate the far-reaching impact of climate change, and select one issue that is impacting global health as a result of climate change. Read about emerging efforts to address the selected climate change issue and consider additional solutions to prepare for its impact and to advocate for improved…

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    Assignment Prompt & Instructions

    Investigate the far-reaching impact of climate change, and select one issue that is impacting global health as a result of climate change. Read about emerging efforts to address the selected climate change issue and consider additional solutions to prepare for its impact and to advocate for improved outcomes.In a **2** pages, address the elements below. Use a minimum of 3 peer-reviewed scholarly sources, current within **5** years, to support your work.

    1. Provide an introduction to the paper.
    2. Identify and describe one issue that is impacting global health as a result of climate change. Explain how this issue influences global health and the health of individuals. Describe current efforts to address this climate change-related health concern.
    3. Propose one strategy at the local level to prepare for or address the impact of this issue and explain the resources that would be needed. Discuss how the strategy would impact the health of individuals locally as well as global health.
    4. Provide a summary of the paper.

    #### Assignment Instructions:

    1. The title page, pagination, subheadings, body of the paper, citation of sources, and reference page must follow APA guidelines as found in the most current edition of the manual.
    2. Rules of grammar, spelling, word usage, punctuation, sentence and paragraph structure are followed and consistent with formal, scholarly writing as noted in the most current edition of the APA Manual.
    3. **No more than one short, direct quote (15 words or less) may be used in this assignment.**
    4. **First-person should not be used within this assignment.**

    **NO PLAGIO MORE THAN 10% ALLOWEDDUE DATE JANUARY 22, 2025**

    – 2 years ago

  • [Solved] Explain discussion

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    Explain discussion – 2 years ago

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    Assignment Prompt & Instructions

    Explain discussion

    – 2 years ago

  • [Solved] Discussion using a APA7 format and scholarly references no older than 5 years.

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    For each course, you will be required a reflective discussion on how the course outcomes, the program outcomes, and the DNP Essentials were achieved throughout the course. Please familiarize yourself with each essential. Select two essentials and explain how you will be incorporating them into your …

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    Assignment Prompt & Instructions

    For each course, you will be required a reflective discussion on how the course outcomes, the program outcomes, and the DNP Essentials were achieved throughout the course. Please familiarize yourself with each essential.

    Select two essentials and explain how you will be incorporating them into your practicum project as a DNP student. In Addition, select three leadership role-specific competencies from the AONL packet and explain how you will be achieving those during the DNP journey.

    – [\
    \
    AONEcompetences2.pdf](https://www.sweetstudy.com/files/aonecompetences2-pdf "AONEcompetences2.pdf")
    – [\
    \
    DNPEssentials.pdf](https://www.sweetstudy.com/files/dnpessentials-pdf-10161445 "DNPEssentials.pdf")

    – 2 years ago

  • [Solved] soap note pt 2

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    review by rubric and add references – 2 years ago **files (2)** – ## MSNSoapNoteRubricElsaPreceptor.pdf – ## SoapNotetrachandStentPatient.docx **## MSNSoapNoteRubricElsaPreceptor.pdf** SOAP NOTE RUBRIC Criteria Points Competent Need Improvement Not Acceptable Score Subjective (35 points) Provides co…

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    Assignment Prompt & Instructions

    review by rubric and add references

    – 2 years ago

    **files (2)**

    – ## MSNSoapNoteRubricElsaPreceptor.pdf

    – ## SoapNotetrachandStentPatient.docx

    **## MSNSoapNoteRubricElsaPreceptor.pdf**

    SOAP NOTE RUBRIC

    Criteria Points Competent Need Improvement Not Acceptable

    Score

    Subjective (35 points) Provides
    complete, concise,
    and accurate
    information,
    which is well
    organized and
    easy to
    understand.

    Provides most of the
    pertinent
    information, but is
    not well organized
    and/or is slightly
    challenging to
    understand. May be
    missing pertinent
    negative information
    (e.g., patient
    denies…).

    Limited or no
    summary of
    pertinent
    information, is
    organized
    poorly, contains
    inaccurate
    information,
    and/or is
    difficult to
    understand.

    Chief complaint 5 5 3 1
    HPI 10 10 8 6
    Relevant PMH & FH 5 5 3 1
    ROS 10 10 8 6
    Currents: Allergies,
    Meds/OTCs, Tobacco,
    Immunizations, Diet, Exercise,
    Sleep

    5 5 3 1

    Objective (40 points) Provides
    complete, concise,
    and accurate
    information,
    which is well
    organized and
    easy to
    understand.

    Provides most of the
    pertinent
    information, but is
    not well organized
    and/or is slightly
    challenging to
    understand. May be
    missing pertinent
    negative information
    (e.g., patient denies)

    Limited or no
    summary of
    pertinent
    information, is
    organized
    poorly, contains
    inaccurate
    information,
    and/or is
    difficult to
    understand.

    General survey (Describe the
    state of the patient at the time
    of the examination)

    10 10 8 6

    Vital signs
    Height, Weight, BMI

    10 10 8 6

    Physical exam-systematic,
    organized and thorough and
    related to the reason of the visit

    20 20 18 16

    Diagnosis/ Differentials
    Diagnosis (10 points)

    Main diagnosis/
    Differentials
    Diagnosis is
    supported by the
    objective and
    subjective
    assessment and
    rationale for
    choosing the

    Main diagnosis/
    Differentials
    Diagnosis is
    supported by the
    objective and
    subjective assessment
    but the rationale for
    choosing the
    diagnosis is not

    Main diagnosis/
    Differentials
    Diagnosis is not
    supported by
    the objective
    and subjective
    assessment and
    the rationale for
    choosing the

    SOAP NOTE RUBRIC

    diagnosis is
    supported by the
    evidence

    supported by the
    evidence

    diagnosis is not
    supported by
    the evidence

    Diagnosis/(Assessment) 5 5 3 1
    List of differentials supported
    by S+O findings (5 points)
    Must provide 3 differential
    diagnoses with one citation
    for each diagnosis.

    5 5 3 1

    Plan of care (10 Points) Complete and
    appropriate plan
    for the main
    problem and
    other active
    problems.
    Includes
    pharmacologic
    and/or non-
    pharmacologic
    and/or complete
    sig components.

    Mostly complete and
    appropriate plan for
    the main problem
    and other active
    problems. May be
    missing appropriate
    non-pharmacologic
    treatments and/or sig
    components.

    Missing or
    inappropriate
    treatment plan
    for the main
    problem and
    other active
    problems.

    Diagnostic
    tests/therapies/medications

    5 5 3 1

    Follow-up/Pt. Education and
    Health Promotion

    5 5 3 1

    References (5 Points) Provides a
    complete and
    appropriate list of
    references that
    are in APA
    format.

    References listed are
    appropriate (i.e.
    guidelines or
    primary), but not
    complete and some
    may be missing. Not
    APA formatted.

    References
    missing or very
    limited.
    References
    listed are
    inappropriate
    (i.e. tertiary)
    and/or not
    relevant.

    References 5 5 3 1
    Total 100

    Comment:

    **## SoapNotetrachandStentPatient.docx**

    | | | |
    | — | — | — |
    | **Patient Initials: MR** | **Pt. Encounter Number: 2-5** |
    | **Date: 1/15/2025** | **Age: 70 y.o** | **Sex: Male** |
    | **Allergies: NKA Advanced Directives: On File** |
    | **SUBJECTIVE** |
    | **CC:**<br>_Nurse from Step down reports increased Shortness of breath, sputum production, labored breathing, hypoxia and fever._ |
    | **HPI:** 70 year old male presents to the hospital with shortness of breath, cough and fever for 5 days. Today with worsening dyspnea, reports increased thick yellow secretions through tracheostomy and hypoxia. Hx of HIV, multinodular goiter, COPD, tracheal compression most likely due to extrinsic compression due to enlarged thyroid s/p Bronchoscopy Rigid with Placement Tracheal Stent with Airway Dilation, Laser on 1/12/25. Pt was transferred to ICU do to hypoxemic respiratory insufficiency, placed on Bipap overnight, switch to HFNC 40L/100, and stent migration to carina level that needed close monitoring in the ICU.<br> <br>**_Onset:_** 5 days ago <br> <br>**_Location:_** Chest Discomfort with Inspiration, throat pain<br> <br>**_Duration:_** Intermittent<br> <br>**_Characteristics:_** Sore throat, sore back and chest.<br> <br>**_Aggravating Factors:_** While coughing. When Laying Flat <br> <br>**_Relieving Factors:_** Respiratory treatments, Sleeping with HOB elevated, Suctioning.<br> <br>**_Treatment:_** CT ABD Scan STAT ordered, Surgical team on board, labs CBC, BMP, Aptt, PT/INR, blood cx. Close monitoring in ICU. |
    | **Current Medications:**<br>Albuterol 180 mcg Inhaler, Mucomyst 200 mg/ml solution 600 mg, Ipratropium-albuterol (Duoneb) 0.5 mg-3 mg Neb Solution,<br>Cefepime 2 G in sodium chloride 0.9 % 100 ml IVPB, Peridex 0.12 % solution 15 ml. Solumedrol 60 mg IV push<br>Insulin regular 100 unit/ml Sliding scale. <br>Cardura 4 mg HS<br>Flomax 0.4 mg QD<br>Pantoprazole 40 mg IV Push QD<br>Cobicistat 150 mg Tab, Darunavir 800 mg tab, Dolutegravir 50 mg tab. <br>Precedex 400 mcg in sodium chloride 0.9 % infusion titrate as per orders. Lexapro 20 tab.<br>Zyprexa 20 mg HS<br>Zolpidem (Ambien) 10 mg Tab HS. |
    | **PMH:**<br>HIV, multinodular goiter, COPD, DM, BPH, Depression, Tracheostomy.<br>**Medication Intolerances: None**<br>**Chronic Illnesses/Major traumas:** HIV, COPD, IDDM<br> <br>**Screening Hx/Immunizations Hx:** Up to Date, Influenza and Pneumococcal. <br> <br>**Hospitalizations/Surgeries:**<br>s/p Bronchoscopy Rigid with Placement Tracheal Stent with Airway Dilation, Laser on 1/12/25 |
    | **Family History:**<br>Father-60 years old died from Lung Cancer. <br>Mother-72 years old died from Heart Attack. |
    | **Social History:**<br>_Patient comes from LTACH. Smoked in the past, denies alcohol or drug us. Non-Ambulatory. Requires frequent repositioning to prevent bedsores. Fall precautions and Aspiration precautions in place._ |
    | **ROS** |
    | **General**<br>AAOx1. Appears fatigued and mild respiratory distress. | **Cardiovascular**<br>· Hemodynamic monitoring and management. <br>· Continue Cardura 4 mg. |
    | **Skin**<br>Normal, Warm and Dry. Good skin turgor. | **Respiratory**<br>· Strict airway monitoring due to mass and stent migration to carina.<br>· Continue Cefepime for multifocal PNA<br>· HFNC, NRM w/ heliox treatment<br>· Continue nebulizer<br>· Keep FiO2 >92%<br>· Suction PRN |
    | **Eyes**<br>Denies visual loss, blurred vision, or double vision. Denies history of cataracts or glaucoma. Uses glasses. | **Gastrointestinal**<br>· NPO Status<br>· Gi Px: Protonix |
    | **Ears**<br>Denies recent infections, ear pain, or tinnitus. Hard of hearing. | **Genitourinary/Gynecological**<br>No acute issues: Denies urinary urgency, frequency, dysuria, odorous urine, suprapubic pain.<br>· Continue monitoring of renal function, I/O, and electrolytes. Replace PRN.<br>· Maintenance IV Fluids at 50 ml/hr.<br>· CKD (Baseline Cr 1.5) <br>· Continue Flomax to prevent urinary retention. |

    | | | |
    | — | — | — |
    | | |
    | **Nose/Mouth/Throat**<br>Denies nasal pain, drainage, congestion, or other sinus issues. Denies throat pain or swelling. | **Musculoskeletal**<br>ROM limited. Bedbound. <br>· PT/OT ordered<br>· OOB to Chair |
    | **Breast**<br>Denies discharge, tenderness. No palpable mass during exam. | **Neurological**<br>Sleeping, arousable upon calling. AAOx1 |
    | **Heme/Lymph/Endo**<br>· Afebrile<br>· Leukocytosis <br>· Continue HART Meds. <br>· Pending OR this week for migrated Stent in the Carina. | **Psychiatric**<br>· AAOx1<br>· Continue Lexapro 20 QD<br>· Continue Zyprexa 20 mg and Ambien 10 mg HD<br>· Titrate Precedex as ordered. |
    | **OBJECTIVE** |
    | **Weight 167 lbs BMI 26.30 kg/m** | **Temp 98.1** | **BP 107/57** |
    | **Height 5’7”** | **Pulse 65** | **Resp 20** |
    | **PHYSICAL EXAMINATION** |
    | **General Appearance**<br>Patients currently sleeping, easy to arouse. Weakness, fatigued. No distress noted. Denies pain or discomfort at the moment. |
    | **Skin**<br>Skin is intact, warm, dry, and adequate color. Normal skin turgor. Capillary refills < 3 seconds. |
    | **HEENT**<br>Head in normocephalic/atraumatic. Visual field full by confrontation. Conjunctiva pink, sclera white. Pupils 3 mm equally, round react to light and accommodation. EOM intact. No nose discharged noted. Fontal sinuses non-tender to palpation. No bleeding gum noted. Buccal mucosa dry, pink, and intact. Uvula midline, no exudate noted. Tracheostomy noted. No JVD noted. |
    | **Cardiovascular**<br>Currently NSR. No murmurs noted upon auscultation. Denies Chest Pain. |
    | **Respiratory**<br>Diminished breath sounds to auscultation bilaterally. No wheezing or stridor noted. Saturation 99-100 % on HFNC 40 L/100%. |
    | **Gastrointestinal**<br>Abdomen soft, non-distended, round. Bowel sounds present. Last BM reported yesterday. |
    | **Breast**<br>No lumps noted on palpation. Symmetrical. |
    | **Genitourinary**<br>No inguinal Hernias or CVA tenderness. Urine clear and yellow. Monitor I/O. |
    | **Musculoskeletal**<br>Frequent repositioning. OOB to chair with PT. Weaknesses. Limited ROM. No cyanosis or pedal edema. |
    | **Neurological**<br>AAOx1 to self, disoriented to situation, time, place. Speech clear. Following simple commands. Weakness BL upper and Lower extremities. Denies headache or dizziness. |
    | **Psychiatric**<br>Patient with hx depression and anxiety. Calm and pleasantly confused at the moment. |
    | **Lab Tests:**<br>CBC, BMP, aPtt, PT/INR,<br> <br>Blood cx, Urine Analysis, Sputum Cultures<br>ABG to evaluate hypoxemia and hypercapnia.<br>CD4 count and HIV viral load to assess immune status |

    | |
    | — |
    | |
    | **Special Tests:** Surgical Consult, CT Chest and Neck w/o contrast, Chest Xray To asses for PNA and stent positioning. |
    | **Diagnosis** |
    | · Primary Diagnosis- <br>· J96.01 – Acute Respiratory Failure with Hypoxia<br>· Z93.0 Tracheostomy status<br>· R09.02- Hypoxemia<br>· R50.9- Fever, unspecified.<br>· J38.4 – Edema of Larynx <br>o Differential Diagnoses<br>**:** Acute COPD exacerbation. Thyroid-Related Airway Compression. Stent related Complications. Infectious Process likely bacterial tracheitis or Pneumonia. <br> <br>o<br>**Plan:**<br> Daily CT chest and neck, Chest Xray, and Labs.<br>· Possible emergent Bronchoscopy if stent causes obstruction.<br>· Referrals for Pulmonology for airway management, Surgical Consult for multinodular goiter and removal of stent. ID following, and PT/OT to mobilize patient and prevent skin breakdown. <br> Continue antibiotics, steroids and Nebulizers Tx.<br> Education: NPO status, importance of repositioning |
    | **References** |

    SOAP NOTE

    **## SoapNotetrachandStentPatient.docx**

    | | | |
    | — | — | — |
    | **Patient Initials: MR** | **Pt. Encounter Number: 2-5** |
    | **Date: 1/15/2025** | **Age: 70 y.o** | **Sex: Male** |
    | **Allergies: NKA Advanced Directives: On File** |
    | **SUBJECTIVE** |
    | **CC:**<br>_Nurse from Step down reports increased Shortness of breath, sputum production, labored breathing, hypoxia and fever._ |
    | **HPI:** 70 year old male presents to the hospital with shortness of breath, cough and fever for 5 days. Today with worsening dyspnea, reports increased thick yellow secretions through tracheostomy and hypoxia. Hx of HIV, multinodular goiter, COPD, tracheal compression most likely due to extrinsic compression due to enlarged thyroid s/p Bronchoscopy Rigid with Placement Tracheal Stent with Airway Dilation, Laser on 1/12/25. Pt was transferred to ICU do to hypoxemic respiratory insufficiency, placed on Bipap overnight, switch to HFNC 40L/100, and stent migration to carina level that needed close monitoring in the ICU.<br> <br>**_Onset:_** 5 days ago <br> <br>**_Location:_** Chest Discomfort with Inspiration, throat pain<br> <br>**_Duration:_** Intermittent<br> <br>**_Characteristics:_** Sore throat, sore back and chest.<br> <br>**_Aggravating Factors:_** While coughing. When Laying Flat <br> <br>**_Relieving Factors:_** Respiratory treatments, Sleeping with HOB elevated, Suctioning.<br> <br>**_Treatment:_** CT ABD Scan STAT ordered, Surgical team on board, labs CBC, BMP, Aptt, PT/INR, blood cx. Close monitoring in ICU. |
    | **Current Medications:**<br>Albuterol 180 mcg Inhaler, Mucomyst 200 mg/ml solution 600 mg, Ipratropium-albuterol (Duoneb) 0.5 mg-3 mg Neb Solution,<br>Cefepime 2 G in sodium chloride 0.9 % 100 ml IVPB, Peridex 0.12 % solution 15 ml. Solumedrol 60 mg IV push<br>Insulin regular 100 unit/ml Sliding scale. <br>Cardura 4 mg HS<br>Flomax 0.4 mg QD<br>Pantoprazole 40 mg IV Push QD<br>Cobicistat 150 mg Tab, Darunavir 800 mg tab, Dolutegravir 50 mg tab. <br>Precedex 400 mcg in sodium chloride 0.9 % infusion titrate as per orders. Lexapro 20 tab.<br>Zyprexa 20 mg HS<br>Zolpidem (Ambien) 10 mg Tab HS. |
    | **PMH:**<br>HIV, multinodular goiter, COPD, DM, BPH, Depression, Tracheostomy.<br>**Medication Intolerances: None**<br>**Chronic Illnesses/Major traumas:** HIV, COPD, IDDM<br> <br>**Screening Hx/Immunizations Hx:** Up to Date, Influenza and Pneumococcal. <br> <br>**Hospitalizations/Surgeries:**<br>s/p Bronchoscopy Rigid with Placement Tracheal Stent with Airway Dilation, Laser on 1/12/25 |
    | **Family History:**<br>Father-60 years old died from Lung Cancer. <br>Mother-72 years old died from Heart Attack. |
    | **Social History:**<br>_Patient comes from LTACH. Smoked in the past, denies alcohol or drug us. Non-Ambulatory. Requires frequent repositioning to prevent bedsores. Fall precautions and Aspiration precautions in place._ |
    | **ROS** |
    | **General**<br>AAOx1. Appears fatigued and mild respiratory distress. | **Cardiovascular**<br>· Hemodynamic monitoring and management. <br>· Continue Cardura 4 mg. |
    | **Skin**<br>Normal, Warm and Dry. Good skin turgor. | **Respiratory**<br>· Strict airway monitoring due to mass and stent migration to carina.<br>· Continue Cefepime for multifocal PNA<br>· HFNC, NRM w/ heliox treatment<br>· Continue nebulizer<br>· Keep FiO2 >92%<br>· Suction PRN |
    | **Eyes**<br>Denies visual loss, blurred vision, or double vision. Denies history of cataracts or glaucoma. Uses glasses. | **Gastrointestinal**<br>· NPO Status<br>· Gi Px: Protonix |
    | **Ears**<br>Denies recent infections, ear pain, or tinnitus. Hard of hearing. | **Genitourinary/Gynecological**<br>No acute issues: Denies urinary urgency, frequency, dysuria, odorous urine, suprapubic pain.<br>· Continue monitoring of renal function, I/O, and electrolytes. Replace PRN.<br>· Maintenance IV Fluids at 50 ml/hr.<br>· CKD (Baseline Cr 1.5) <br>· Continue Flomax to prevent urinary retention. |

    | | | |
    | — | — | — |
    | | |
    | **Nose/Mouth/Throat**<br>Denies nasal pain, drainage, congestion, or other sinus issues. Denies throat pain or swelling. | **Musculoskeletal**<br>ROM limited. Bedbound. <br>· PT/OT ordered<br>· OOB to Chair |
    | **Breast**<br>Denies discharge, tenderness. No palpable mass during exam. | **Neurological**<br>Sleeping, arousable upon calling. AAOx1 |
    | **Heme/Lymph/Endo**<br>· Afebrile<br>· Leukocytosis <br>· Continue HART Meds. <br>· Pending OR this week for migrated Stent in the Carina. | **Psychiatric**<br>· AAOx1<br>· Continue Lexapro 20 QD<br>· Continue Zyprexa 20 mg and Ambien 10 mg HD<br>· Titrate Precedex as ordered. |
    | **OBJECTIVE** |
    | **Weight 167 lbs BMI 26.30 kg/m** | **Temp 98.1** | **BP 107/57** |
    | **Height 5’7”** | **Pulse 65** | **Resp 20** |
    | **PHYSICAL EXAMINATION** |
    | **General Appearance**<br>Patients currently sleeping, easy to arouse. Weakness, fatigued. No distress noted. Denies pain or discomfort at the moment. |
    | **Skin**<br>Skin is intact, warm, dry, and adequate color. Normal skin turgor. Capillary refills < 3 seconds. |
    | **HEENT**<br>Head in normocephalic/atraumatic. Visual field full by confrontation. Conjunctiva pink, sclera white. Pupils 3 mm equally, round react to light and accommodation. EOM intact. No nose discharged noted. Fontal sinuses non-tender to palpation. No bleeding gum noted. Buccal mucosa dry, pink, and intact. Uvula midline, no exudate noted. Tracheostomy noted. No JVD noted. |
    | **Cardiovascular**<br>Currently NSR. No murmurs noted upon auscultation. Denies Chest Pain. |
    | **Respiratory**<br>Diminished breath sounds to auscultation bilaterally. No wheezing or stridor noted. Saturation 99-100 % on HFNC 40 L/100%. |
    | **Gastrointestinal**<br>Abdomen soft, non-distended, round. Bowel sounds present. Last BM reported yesterday. |
    | **Breast**<br>No lumps noted on palpation. Symmetrical. |
    | **Genitourinary**<br>No inguinal Hernias or CVA tenderness. Urine clear and yellow. Monitor I/O. |
    | **Musculoskeletal**<br>Frequent repositioning. OOB to chair with PT. Weaknesses. Limited ROM. No cyanosis or pedal edema. |
    | **Neurological**<br>AAOx1 to self, disoriented to situation, time, place. Speech clear. Following simple commands. Weakness BL upper and Lower extremities. Denies headache or dizziness. |
    | **Psychiatric**<br>Patient with hx depression and anxiety. Calm and pleasantly confused at the moment. |
    | **Lab Tests:**<br>CBC, BMP, aPtt, PT/INR,<br> <br>Blood cx, Urine Analysis, Sputum Cultures<br>ABG to evaluate hypoxemia and hypercapnia.<br>CD4 count and HIV viral load to assess immune status |

    | |
    | — |
    | |
    | **Special Tests:** Surgical Consult, CT Chest and Neck w/o contrast, Chest Xray To asses for PNA and stent positioning. |
    | **Diagnosis** |
    | · Primary Diagnosis- <br>· J96.01 – Acute Respiratory Failure with Hypoxia<br>· Z93.0 Tracheostomy status<br>· R09.02- Hypoxemia<br>· R50.9- Fever, unspecified.<br>· J38.4 – Edema of Larynx <br>o Differential Diagnoses<br>**:** Acute COPD exacerbation. Thyroid-Related Airway Compression. Stent related Complications. Infectious Process likely bacterial tracheitis or Pneumonia. <br> <br>o<br>**Plan:**<br> Daily CT chest and neck, Chest Xray, and Labs.<br>· Possible emergent Bronchoscopy if stent causes obstruction.<br>· Referrals for Pulmonology for airway management, Surgical Consult for multinodular goiter and removal of stent. ID following, and PT/OT to mobilize patient and prevent skin breakdown. <br> Continue antibiotics, steroids and Nebulizers Tx.<br> Education: NPO status, importance of repositioning |
    | **References** |

    SOAP NOTE

    **## MSNSoapNoteRubricElsaPreceptor.pdf**

    SOAP NOTE RUBRIC

    Criteria Points Competent Need Improvement Not Acceptable

    Score

    Subjective (35 points) Provides
    complete, concise,
    and accurate
    information,
    which is well
    organized and
    easy to
    understand.

    Provides most of the
    pertinent
    information, but is
    not well organized
    and/or is slightly
    challenging to
    understand. May be
    missing pertinent
    negative information
    (e.g., patient
    denies…).

    Limited or no
    summary of
    pertinent
    information, is
    organized
    poorly, contains
    inaccurate
    information,
    and/or is
    difficult to
    understand.

    Chief complaint 5 5 3 1
    HPI 10 10 8 6
    Relevant PMH & FH 5 5 3 1
    ROS 10 10 8 6
    Currents: Allergies,
    Meds/OTCs, Tobacco,
    Immunizations, Diet, Exercise,
    Sleep

    5 5 3 1

    Objective (40 points) Provides
    complete, concise,
    and accurate
    information,
    which is well
    organized and
    easy to
    understand.

    Provides most of the
    pertinent
    information, but is
    not well organized
    and/or is slightly
    challenging to
    understand. May be
    missing pertinent
    negative information
    (e.g., patient denies)

    Limited or no
    summary of
    pertinent
    information, is
    organized
    poorly, contains
    inaccurate
    information,
    and/or is
    difficult to
    understand.

    General survey (Describe the
    state of the patient at the time
    of the examination)

    10 10 8 6

    Vital signs
    Height, Weight, BMI

    10 10 8 6

    Physical exam-systematic,
    organized and thorough and
    related to the reason of the visit

    20 20 18 16

    Diagnosis/ Differentials
    Diagnosis (10 points)

    Main diagnosis/
    Differentials
    Diagnosis is
    supported by the
    objective and
    subjective
    assessment and
    rationale for
    choosing the

    Main diagnosis/
    Differentials
    Diagnosis is
    supported by the
    objective and
    subjective assessment
    but the rationale for
    choosing the
    diagnosis is not

    Main diagnosis/
    Differentials
    Diagnosis is not
    supported by
    the objective
    and subjective
    assessment and
    the rationale for
    choosing the

    SOAP NOTE RUBRIC

    diagnosis is
    supported by the
    evidence

    supported by the
    evidence

    diagnosis is not
    supported by
    the evidence

    Diagnosis/(Assessment) 5 5 3 1
    List of differentials supported
    by S+O findings (5 points)
    Must provide 3 differential
    diagnoses with one citation
    for each diagnosis.

    5 5 3 1

    Plan of care (10 Points) Complete and
    appropriate plan
    for the main
    problem and
    other active
    problems.
    Includes
    pharmacologic
    and/or non-
    pharmacologic
    and/or complete
    sig components.

    Mostly complete and
    appropriate plan for
    the main problem
    and other active
    problems. May be
    missing appropriate
    non-pharmacologic
    treatments and/or sig
    components.

    Missing or
    inappropriate
    treatment plan
    for the main
    problem and
    other active
    problems.

    Diagnostic
    tests/therapies/medications

    5 5 3 1

    Follow-up/Pt. Education and
    Health Promotion

    5 5 3 1

    References (5 Points) Provides a
    complete and
    appropriate list of
    references that
    are in APA
    format.

    References listed are
    appropriate (i.e.
    guidelines or
    primary), but not
    complete and some
    may be missing. Not
    APA formatted.

    References
    missing or very
    limited.
    References
    listed are
    inappropriate
    (i.e. tertiary)
    and/or not
    relevant.

    References 5 5 3 1
    Total 100

    Comment:

    **## SoapNotetrachandStentPatient.docx**

    | | | |
    | — | — | — |
    | **Patient Initials: MR** | **Pt. Encounter Number: 2-5** |
    | **Date: 1/15/2025** | **Age: 70 y.o** | **Sex: Male** |
    | **Allergies: NKA Advanced Directives: On File** |
    | **SUBJECTIVE** |
    | **CC:**<br>_Nurse from Step down reports increased Shortness of breath, sputum production, labored breathing, hypoxia and fever._ |
    | **HPI:** 70 year old male presents to the hospital with shortness of breath, cough and fever for 5 days. Today with worsening dyspnea, reports increased thick yellow secretions through tracheostomy and hypoxia. Hx of HIV, multinodular goiter, COPD, tracheal compression most likely due to extrinsic compression due to enlarged thyroid s/p Bronchoscopy Rigid with Placement Tracheal Stent with Airway Dilation, Laser on 1/12/25. Pt was transferred to ICU do to hypoxemic respiratory insufficiency, placed on Bipap overnight, switch to HFNC 40L/100, and stent migration to carina level that needed close monitoring in the ICU.<br> <br>**_Onset:_** 5 days ago <br> <br>**_Location:_** Chest Discomfort with Inspiration, throat pain<br> <br>**_Duration:_** Intermittent<br> <br>**_Characteristics:_** Sore throat, sore back and chest.<br> <br>**_Aggravating Factors:_** While coughing. When Laying Flat <br> <br>**_Relieving Factors:_** Respiratory treatments, Sleeping with HOB elevated, Suctioning.<br> <br>**_Treatment:_** CT ABD Scan STAT ordered, Surgical team on board, labs CBC, BMP, Aptt, PT/INR, blood cx. Close monitoring in ICU. |
    | **Current Medications:**<br>Albuterol 180 mcg Inhaler, Mucomyst 200 mg/ml solution 600 mg, Ipratropium-albuterol (Duoneb) 0.5 mg-3 mg Neb Solution,<br>Cefepime 2 G in sodium chloride 0.9 % 100 ml IVPB, Peridex 0.12 % solution 15 ml. Solumedrol 60 mg IV push<br>Insulin regular 100 unit/ml Sliding scale. <br>Cardura 4 mg HS<br>Flomax 0.4 mg QD<br>Pantoprazole 40 mg IV Push QD<br>Cobicistat 150 mg Tab, Darunavir 800 mg tab, Dolutegravir 50 mg tab. <br>Precedex 400 mcg in sodium chloride 0.9 % infusion titrate as per orders. Lexapro 20 tab.<br>Zyprexa 20 mg HS<br>Zolpidem (Ambien) 10 mg Tab HS. |
    | **PMH:**<br>HIV, multinodular goiter, COPD, DM, BPH, Depression, Tracheostomy.<br>**Medication Intolerances: None**<br>**Chronic Illnesses/Major traumas:** HIV, COPD, IDDM<br> <br>**Screening Hx/Immunizations Hx:** Up to Date, Influenza and Pneumococcal. <br> <br>**Hospitalizations/Surgeries:**<br>s/p Bronchoscopy Rigid with Placement Tracheal Stent with Airway Dilation, Laser on 1/12/25 |
    | **Family History:**<br>Father-60 years old died from Lung Cancer. <br>Mother-72 years old died from Heart Attack. |
    | **Social History:**<br>_Patient comes from LTACH. Smoked in the past, denies alcohol or drug us. Non-Ambulatory. Requires frequent repositioning to prevent bedsores. Fall precautions and Aspiration precautions in place._ |
    | **ROS** |
    | **General**<br>AAOx1. Appears fatigued and mild respiratory distress. | **Cardiovascular**<br>· Hemodynamic monitoring and management. <br>· Continue Cardura 4 mg. |
    | **Skin**<br>Normal, Warm and Dry. Good skin turgor. | **Respiratory**<br>· Strict airway monitoring due to mass and stent migration to carina.<br>· Continue Cefepime for multifocal PNA<br>· HFNC, NRM w/ heliox treatment<br>· Continue nebulizer<br>· Keep FiO2 >92%<br>· Suction PRN |
    | **Eyes**<br>Denies visual loss, blurred vision, or double vision. Denies history of cataracts or glaucoma. Uses glasses. | **Gastrointestinal**<br>· NPO Status<br>· Gi Px: Protonix |
    | **Ears**<br>Denies recent infections, ear pain, or tinnitus. Hard of hearing. | **Genitourinary/Gynecological**<br>No acute issues: Denies urinary urgency, frequency, dysuria, odorous urine, suprapubic pain.<br>· Continue monitoring of renal function, I/O, and electrolytes. Replace PRN.<br>· Maintenance IV Fluids at 50 ml/hr.<br>· CKD (Baseline Cr 1.5) <br>· Continue Flomax to prevent urinary retention. |

    | | | |
    | — | — | — |
    | | |
    | **Nose/Mouth/Throat**<br>Denies nasal pain, drainage, congestion, or other sinus issues. Denies throat pain or swelling. | **Musculoskeletal**<br>ROM limited. Bedbound. <br>· PT/OT ordered<br>· OOB to Chair |
    | **Breast**<br>Denies discharge, tenderness. No palpable mass during exam. | **Neurological**<br>Sleeping, arousable upon calling. AAOx1 |
    | **Heme/Lymph/Endo**<br>· Afebrile<br>· Leukocytosis <br>· Continue HART Meds. <br>· Pending OR this week for migrated Stent in the Carina. | **Psychiatric**<br>· AAOx1<br>· Continue Lexapro 20 QD<br>· Continue Zyprexa 20 mg and Ambien 10 mg HD<br>· Titrate Precedex as ordered. |
    | **OBJECTIVE** |
    | **Weight 167 lbs BMI 26.30 kg/m** | **Temp 98.1** | **BP 107/57** |
    | **Height 5’7”** | **Pulse 65** | **Resp 20** |
    | **PHYSICAL EXAMINATION** |
    | **General Appearance**<br>Patients currently sleeping, easy to arouse. Weakness, fatigued. No distress noted. Denies pain or discomfort at the moment. |
    | **Skin**<br>Skin is intact, warm, dry, and adequate color. Normal skin turgor. Capillary refills < 3 seconds. |
    | **HEENT**<br>Head in normocephalic/atraumatic. Visual field full by confrontation. Conjunctiva pink, sclera white. Pupils 3 mm equally, round react to light and accommodation. EOM intact. No nose discharged noted. Fontal sinuses non-tender to palpation. No bleeding gum noted. Buccal mucosa dry, pink, and intact. Uvula midline, no exudate noted. Tracheostomy noted. No JVD noted. |
    | **Cardiovascular**<br>Currently NSR. No murmurs noted upon auscultation. Denies Chest Pain. |
    | **Respiratory**<br>Diminished breath sounds to auscultation bilaterally. No wheezing or stridor noted. Saturation 99-100 % on HFNC 40 L/100%. |
    | **Gastrointestinal**<br>Abdomen soft, non-distended, round. Bowel sounds present. Last BM reported yesterday. |
    | **Breast**<br>No lumps noted on palpation. Symmetrical. |
    | **Genitourinary**<br>No inguinal Hernias or CVA tenderness. Urine clear and yellow. Monitor I/O. |
    | **Musculoskeletal**<br>Frequent repositioning. OOB to chair with PT. Weaknesses. Limited ROM. No cyanosis or pedal edema. |
    | **Neurological**<br>AAOx1 to self, disoriented to situation, time, place. Speech clear. Following simple commands. Weakness BL upper and Lower extremities. Denies headache or dizziness. |
    | **Psychiatric**<br>Patient with hx depression and anxiety. Calm and pleasantly confused at the moment. |
    | **Lab Tests:**<br>CBC, BMP, aPtt, PT/INR,<br> <br>Blood cx, Urine Analysis, Sputum Cultures<br>ABG to evaluate hypoxemia and hypercapnia.<br>CD4 count and HIV viral load to assess immune status |

    | |
    | — |
    | |
    | **Special Tests:** Surgical Consult, CT Chest and Neck w/o contrast, Chest Xray To asses for PNA and stent positioning. |
    | **Diagnosis** |
    | · Primary Diagnosis- <br>· J96.01 – Acute Respiratory Failure with Hypoxia<br>· Z93.0 Tracheostomy status<br>· R09.02- Hypoxemia<br>· R50.9- Fever, unspecified.<br>· J38.4 – Edema of Larynx <br>o Differential Diagnoses<br>**:** Acute COPD exacerbation. Thyroid-Related Airway Compression. Stent related Complications. Infectious Process likely bacterial tracheitis or Pneumonia. <br> <br>o<br>**Plan:**<br> Daily CT chest and neck, Chest Xray, and Labs.<br>· Possible emergent Bronchoscopy if stent causes obstruction.<br>· Referrals for Pulmonology for airway management, Surgical Consult for multinodular goiter and removal of stent. ID following, and PT/OT to mobilize patient and prevent skin breakdown. <br> Continue antibiotics, steroids and Nebulizers Tx.<br> Education: NPO status, importance of repositioning |
    | **References** |

    SOAP NOTE

    **## MSNSoapNoteRubricElsaPreceptor.pdf**

    SOAP NOTE RUBRIC

    Criteria Points Competent Need Improvement Not Acceptable

    Score

    Subjective (35 points) Provides
    complete, concise,
    and accurate
    information,
    which is well
    organized and
    easy to
    understand.

    Provides most of the
    pertinent
    information, but is
    not well organized
    and/or is slightly
    challenging to
    understand. May be
    missing pertinent
    negative information
    (e.g., patient
    denies…).

    Limited or no
    summary of
    pertinent
    information, is
    organized
    poorly, contains
    inaccurate
    information,
    and/or is
    difficult to
    understand.

    Chief complaint 5 5 3 1
    HPI 10 10 8 6
    Relevant PMH & FH 5 5 3 1
    ROS 10 10 8 6
    Currents: Allergies,
    Meds/OTCs, Tobacco,
    Immunizations, Diet, Exercise,
    Sleep

    5 5 3 1

    Objective (40 points) Provides
    complete, concise,
    and accurate
    information,
    which is well
    organized and
    easy to
    understand.

    Provides most of the
    pertinent
    information, but is
    not well organized
    and/or is slightly
    challenging to
    understand. May be
    missing pertinent
    negative information
    (e.g., patient denies)

    Limited or no
    summary of
    pertinent
    information, is
    organized
    poorly, contains
    inaccurate
    information,
    and/or is
    difficult to
    understand.

    General survey (Describe the
    state of the patient at the time
    of the examination)

    10 10 8 6

    Vital signs
    Height, Weight, BMI

    10 10 8 6

    Physical exam-systematic,
    organized and thorough and
    related to the reason of the visit

    20 20 18 16

    Diagnosis/ Differentials
    Diagnosis (10 points)

    Main diagnosis/
    Differentials
    Diagnosis is
    supported by the
    objective and
    subjective
    assessment and
    rationale for
    choosing the

    Main diagnosis/
    Differentials
    Diagnosis is
    supported by the
    objective and
    subjective assessment
    but the rationale for
    choosing the
    diagnosis is not

    Main diagnosis/
    Differentials
    Diagnosis is not
    supported by
    the objective
    and subjective
    assessment and
    the rationale for
    choosing the

    SOAP NOTE RUBRIC

    diagnosis is
    supported by the
    evidence

    supported by the
    evidence

    diagnosis is not
    supported by
    the evidence

    Diagnosis/(Assessment) 5 5 3 1
    List of differentials supported
    by S+O findings (5 points)
    Must provide 3 differential
    diagnoses with one citation
    for each diagnosis.

    5 5 3 1

    Plan of care (10 Points) Complete and
    appropriate plan
    for the main
    problem and
    other active
    problems.
    Includes
    pharmacologic
    and/or non-
    pharmacologic
    and/or complete
    sig components.

    Mostly complete and
    appropriate plan for
    the main problem
    and other active
    problems. May be
    missing appropriate
    non-pharmacologic
    treatments and/or sig
    components.

    Missing or
    inappropriate
    treatment plan
    for the main
    problem and
    other active
    problems.

    Diagnostic
    tests/therapies/medications

    5 5 3 1

    Follow-up/Pt. Education and
    Health Promotion

    5 5 3 1

    References (5 Points) Provides a
    complete and
    appropriate list of
    references that
    are in APA
    format.

    References listed are
    appropriate (i.e.
    guidelines or
    primary), but not
    complete and some
    may be missing. Not
    APA formatted.

    References
    missing or very
    limited.
    References
    listed are
    inappropriate
    (i.e. tertiary)
    and/or not
    relevant.

    References 5 5 3 1
    Total 100

    Comment:

    **## SoapNotetrachandStentPatient.docx**

    | | | |
    | — | — | — |
    | **Patient Initials: MR** | **Pt. Encounter Number: 2-5** |
    | **Date: 1/15/2025** | **Age: 70 y.o** | **Sex: Male** |
    | **Allergies: NKA Advanced Directives: On File** |
    | **SUBJECTIVE** |
    | **CC:**<br>_Nurse from Step down reports increased Shortness of breath, sputum production, labored breathing, hypoxia and fever._ |
    | **HPI:** 70 year old male presents to the hospital with shortness of breath, cough and fever for 5 days. Today with worsening dyspnea, reports increased thick yellow secretions through tracheostomy and hypoxia. Hx of HIV, multinodular goiter, COPD, tracheal compression most likely due to extrinsic compression due to enlarged thyroid s/p Bronchoscopy Rigid with Placement Tracheal Stent with Airway Dilation, Laser on 1/12/25. Pt was transferred to ICU do to hypoxemic respiratory insufficiency, placed on Bipap overnight, switch to HFNC 40L/100, and stent migration to carina level that needed close monitoring in the ICU.<br> <br>**_Onset:_** 5 days ago <br> <br>**_Location:_** Chest Discomfort with Inspiration, throat pain<br> <br>**_Duration:_** Intermittent<br> <br>**_Characteristics:_** Sore throat, sore back and chest.<br> <br>**_Aggravating Factors:_** While coughing. When Laying Flat <br> <br>**_Relieving Factors:_** Respiratory treatments, Sleeping with HOB elevated, Suctioning.<br> <br>**_Treatment:_** CT ABD Scan STAT ordered, Surgical team on board, labs CBC, BMP, Aptt, PT/INR, blood cx. Close monitoring in ICU. |
    | **Current Medications:**<br>Albuterol 180 mcg Inhaler, Mucomyst 200 mg/ml solution 600 mg, Ipratropium-albuterol (Duoneb) 0.5 mg-3 mg Neb Solution,<br>Cefepime 2 G in sodium chloride 0.9 % 100 ml IVPB, Peridex 0.12 % solution 15 ml. Solumedrol 60 mg IV push<br>Insulin regular 100 unit/ml Sliding scale. <br>Cardura 4 mg HS<br>Flomax 0.4 mg QD<br>Pantoprazole 40 mg IV Push QD<br>Cobicistat 150 mg Tab, Darunavir 800 mg tab, Dolutegravir 50 mg tab. <br>Precedex 400 mcg in sodium chloride 0.9 % infusion titrate as per orders. Lexapro 20 tab.<br>Zyprexa 20 mg HS<br>Zolpidem (Ambien) 10 mg Tab HS. |
    | **PMH:**<br>HIV, multinodular goiter, COPD, DM, BPH, Depression, Tracheostomy.<br>**Medication Intolerances: None**<br>**Chronic Illnesses/Major traumas:** HIV, COPD, IDDM<br> <br>**Screening Hx/Immunizations Hx:** Up to Date, Influenza and Pneumococcal. <br> <br>**Hospitalizations/Surgeries:**<br>s/p Bronchoscopy Rigid with Placement Tracheal Stent with Airway Dilation, Laser on 1/12/25 |
    | **Family History:**<br>Father-60 years old died from Lung Cancer. <br>Mother-72 years old died from Heart Attack. |
    | **Social History:**<br>_Patient comes from LTACH. Smoked in the past, denies alcohol or drug us. Non-Ambulatory. Requires frequent repositioning to prevent bedsores. Fall precautions and Aspiration precautions in place._ |
    | **ROS** |
    | **General**<br>AAOx1. Appears fatigued and mild respiratory distress. | **Cardiovascular**<br>· Hemodynamic monitoring and management. <br>· Continue Cardura 4 mg. |
    | **Skin**<br>Normal, Warm and Dry. Good skin turgor. | **Respiratory**<br>· Strict airway monitoring due to mass and stent migration to carina.<br>· Continue Cefepime for multifocal PNA<br>· HFNC, NRM w/ heliox treatment<br>· Continue nebulizer<br>· Keep FiO2 >92%<br>· Suction PRN |
    | **Eyes**<br>Denies visual loss, blurred vision, or double vision. Denies history of cataracts or glaucoma. Uses glasses. | **Gastrointestinal**<br>· NPO Status<br>· Gi Px: Protonix |
    | **Ears**<br>Denies recent infections, ear pain, or tinnitus. Hard of hearing. | **Genitourinary/Gynecological**<br>No acute issues: Denies urinary urgency, frequency, dysuria, odorous urine, suprapubic pain.<br>· Continue monitoring of renal function, I/O, and electrolytes. Replace PRN.<br>· Maintenance IV Fluids at 50 ml/hr.<br>· CKD (Baseline Cr 1.5) <br>· Continue Flomax to prevent urinary retention. |

    | | | |
    | — | — | — |
    | | |
    | **Nose/Mouth/Throat**<br>Denies nasal pain, drainage, congestion, or other sinus issues. Denies throat pain or swelling. | **Musculoskeletal**<br>ROM limited. Bedbound. <br>· PT/OT ordered<br>· OOB to Chair |
    | **Breast**<br>Denies discharge, tenderness. No palpable mass during exam. | **Neurological**<br>Sleeping, arousable upon calling. AAOx1 |
    | **Heme/Lymph/Endo**<br>· Afebrile<br>· Leukocytosis <br>· Continue HART Meds. <br>· Pending OR this week for migrated Stent in the Carina. | **Psychiatric**<br>· AAOx1<br>· Continue Lexapro 20 QD<br>· Continue Zyprexa 20 mg and Ambien 10 mg HD<br>· Titrate Precedex as ordered. |
    | **OBJECTIVE** |
    | **Weight 167 lbs BMI 26.30 kg/m** | **Temp 98.1** | **BP 107/57** |
    | **Height 5’7”** | **Pulse 65** | **Resp 20** |
    | **PHYSICAL EXAMINATION** |
    | **General Appearance**<br>Patients currently sleeping, easy to arouse. Weakness, fatigued. No distress noted. Denies pain or discomfort at the moment. |
    | **Skin**<br>Skin is intact, warm, dry, and adequate color. Normal skin turgor. Capillary refills < 3 seconds. |
    | **HEENT**<br>Head in normocephalic/atraumatic. Visual field full by confrontation. Conjunctiva pink, sclera white. Pupils 3 mm equally, round react to light and accommodation. EOM intact. No nose discharged noted. Fontal sinuses non-tender to palpation. No bleeding gum noted. Buccal mucosa dry, pink, and intact. Uvula midline, no exudate noted. Tracheostomy noted. No JVD noted. |
    | **Cardiovascular**<br>Currently NSR. No murmurs noted upon auscultation. Denies Chest Pain. |
    | **Respiratory**<br>Diminished breath sounds to auscultation bilaterally. No wheezing or stridor noted. Saturation 99-100 % on HFNC 40 L/100%. |
    | **Gastrointestinal**<br>Abdomen soft, non-distended, round. Bowel sounds present. Last BM reported yesterday. |
    | **Breast**<br>No lumps noted on palpation. Symmetrical. |
    | **Genitourinary**<br>No inguinal Hernias or CVA tenderness. Urine clear and yellow. Monitor I/O. |
    | **Musculoskeletal**<br>Frequent repositioning. OOB to chair with PT. Weaknesses. Limited ROM. No cyanosis or pedal edema. |
    | **Neurological**<br>AAOx1 to self, disoriented to situation, time, place. Speech clear. Following simple commands. Weakness BL upper and Lower extremities. Denies headache or dizziness. |
    | **Psychiatric**<br>Patient with hx depression and anxiety. Calm and pleasantly confused at the moment. |
    | **Lab Tests:**<br>CBC, BMP, aPtt, PT/INR,<br> <br>Blood cx, Urine Analysis, Sputum Cultures<br>ABG to evaluate hypoxemia and hypercapnia.<br>CD4 count and HIV viral load to assess immune status |

    | |
    | — |
    | |
    | **Special Tests:** Surgical Consult, CT Chest and Neck w/o contrast, Chest Xray To asses for PNA and stent positioning. |
    | **Diagnosis** |
    | · Primary Diagnosis- <br>· J96.01 – Acute Respiratory Failure with Hypoxia<br>· Z93.0 Tracheostomy status<br>· R09.02- Hypoxemia<br>· R50.9- Fever, unspecified.<br>· J38.4 – Edema of Larynx <br>o Differential Diagnoses<br>**:** Acute COPD exacerbation. Thyroid-Related Airway Compression. Stent related Complications. Infectious Process likely bacterial tracheitis or Pneumonia. <br> <br>o<br>**Plan:**<br> Daily CT chest and neck, Chest Xray, and Labs.<br>· Possible emergent Bronchoscopy if stent causes obstruction.<br>· Referrals for Pulmonology for airway management, Surgical Consult for multinodular goiter and removal of stent. ID following, and PT/OT to mobilize patient and prevent skin breakdown. <br> Continue antibiotics, steroids and Nebulizers Tx.<br> Education: NPO status, importance of repositioning |
    | **References** |

    SOAP NOTE

  • [Solved] SOAP 1 OB

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    Executive Solution Overview

    A SOAP note is a method of documentation employed by healthcare providers to record and communicate patient information in a clear, structured, and in an organized manner. This assignment will provide students with the necessary tools to document patient care effectively, enhance their clinical skil…

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    Assignment Prompt & Instructions

    A SOAP note is a method of documentation employed by healthcare providers to record and communicate patient information in a clear, structured, and in an organized manner. This assignment will provide students with the necessary tools to document patient care effectively, enhance their clinical skills, and prepare them for their roles as competent healthcare providers.

    #### **Instructions:**

    SOAP is an acronym that stands for Subjective, Objective, Assessment, and Plan. The episodic SOAP note is to be written using the attached template below.

    For all the SOAP note assignments, you will write a SOAP note about one of your patients and use the following acronym:

    **S** =Subjective data: Patient’s Chief Complaint (CC). **O** =Objective data: Including client behavior, physical assessment, vital signs, and meds. **A** =Assessment: Diagnosis of the patient's condition. Include differential diagnosis. **P** =Plan: Treatment, diagnostic testing, and follow up

    SOAP Note Rubric **SOAP Note RubricCriteriaRatingsPts**

    Demographics

    **1 to >0.8 pts**

    **Begins with patient initials, age, race, ethnicity and gender (5 demographics)**

    **0.8 to >0.25 pts**

    **Begins with 4 of the 5 patient demographics (patient initials, age, race, ethnicity and gender)**

    **0.25 to >0 pts**

    **Begins with 3 or less patient demographics (patient initials, age, race, ethnicity and gender)**

    **0 pts**

    **Missing criteria and/or submission.**

    / 1 pts

    Chief Complaint (Reason for seeking health care)

    **4 to >3 pts**

    **Includes a direct quote from patient about presenting problem**

    **3 to >2 pts**

    **Includes a direct quote from patient and other unrelated information**

    **2 to >0 pts**

    **Includes information but information is NOT a direct quote**

    **0 pts**

    **Missing criteria and/or submission.**

    / 4 pts

    History of the Present Illness (HPI)

    **5 to >3 pts**

    **Includes the presenting problem and the 8 dimensions of the problem (OLD CARTS – Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing and Severity)**

    **3 to >2 pts**

    **Includes the presenting problem and 7 of the 8 dimensions of the problem (OLD CARTS – Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing and Severity)**

    **2 to >0 pts**

    **Includes the presenting problem and 6 of the 8 dimensions of the problem (OLD CARTS – Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing and Severity)**

    **0 pts**

    **Missing criteria and/or submission.**

    / 5 pts

    Allergies

    **2 to >1.5 pts**

    **Includes NKA (including = Drug, Environmental, Food, Herbal, and/or Latex or if allergies are present (reports for each severity of allergy AND description of allergy)**

    **1.5 to >1 pts**

    **If allergies are present, students lists type Drug, environmental factor, herbal, food, latex name and includes severity of allergy OR description of allergy**

    **1 to >0 pts**

    **If allergies are present, students lists only the type of allergy name**

    **0 pts**

    **Missing criteria and/or submission.**

    / 2 pts

    Review of Systems (ROS)

    **15 to >8 pts**

    **Includes a minimum of 3 assessments for each body system and assesses at least 9 body systems directed to chief complaint AND uses the words “admits” and “denies”**

    **8 to >3 pts**

    **Includes 3 or fewer assessments for each body system and assesses 5-8 body systems directed to chief complaint AND uses the words “admits” and “denies”**

    **3 to >0 pts**

    **Includes 3 or fewer assessments for each body system and assesses less than 5 body systems directed to chief complaint OR student does not use the words “admits” and “denies”**

    **0 pts**

    **Missing criteria and/or submission.**

    / 15 pts

    Vital Signs

    **2 to >1.5 pts**

    **Includes all 8 vital signs, (BP (with patient position), HR, RR, temperature (with Fahrenheit or Celsius and route of temperature collection), weight, height, BMI (or percentiles for pediatric population) and pain.)**

    **1.5 to >1 pts**

    **Includes 7 vital signs, (BP (with patient position), HR, RR, temperature (with Fahrenheit or Celsius and route of temperature collection), weight, height, BMI (or percentiles for pediatric population) and pain.)**

    **1 to >0 pts**

    **Includes 6 or less vital signs, (BP (with patient position), HR, RR, temperature (with F or C and route of temperature collection), weight, height, BMI (or percentiles for pediatric population) and pain.)**

    **0 pts**

    **Missing criteria and/or submission.**

    / 2 pts

    Labs

    **2 to >1.5 pts**

    **Includes a list of the labs reviewed at the visit, values of lab results and highlights abnormal values OR acknowledges no labs/diagnostic tests were reviewed.**

    **1.5 to >1 pts**

    **Includes a list of the labs reviewed at the visit, values of lab results but does not highlight abnormal values.**

    **1 to >0 pts**

    **Includes a list of the labs reviewed at the visit but does not include the values of lab results or highlight abnormal values.**

    **0 pts**

    **Missing criteria and/or submission.**

    / 2 pts

    Medications

    **4 to >2 pts**

    **Includes a list of all of the patient reported medications and the medical diagnosis for the medication (including name, dose, route, frequency)**

    **2 to >1 pts**

    **Includes a list of all of the patient reported medications and the medical diagnosis for the medication (including 3 of the 4: name, dose, medications route, frequency)**

    **1 to >0 pts**

    **Includes a list of all of the patient reported medications (including 2 of the 4: name, dose, route, frequency)**

    **0 pts**

    **Missing criteria and/or submission.**

    / 4 pts

    Past Medical History

    **3 to >2 pts**

    **Includes (Major/Chronic, Trauma, Hospitalizations), for each medical diagnosis, year of diagnosis and whether the diagnosis is active or current**

    **2 to >1 pts**

    **Includes (Major/Chronic, Trauma, Hospitalizations), for each medical diagnosis, either year of diagnosis OR whether the diagnosis is active or current**

    **1 to >0 pts**

    **Includes each medical diagnosis but does not include year of diagnosis or whether the diagnosis is active or current**

    **0 pts**

    **Missing criteria and/or submission.**

    / 3 pts

    Past Surgical History

    **3 to >2 pts**

    **Includes, for each surgical procedure, the year of procedure and the indication for the procedure**

    **2 to >1 pts**

    **Includes, for each surgical procedure, the year of procedure OR indication of the procedure**

    **1 to >0 pts**

    **Includes, for each surgical procedure but not the year of procedure or indication of the procedure**

    **0 pts**

    **Missing criteria and/or submission.**

    / 3 pts

    Family History

    **3 to >2 pts**

    **Includes an assessment of at least 4 family members regarding, at a minimum, genetic disorders, diabetes, heart disease and cancer.**

    **2 to >1 pts**

    **Includes an assessment of at least 3 family members regarding, at a minimum, genetic disorders, diabetes, heart disease and cancer.**

    **1 to >0 pts**

    **Includes an assessment of at least 2 family members regarding, at a minimum, genetic disorders, diabetes, heart disease and cancer.**

    **0 pts**

    **Missing criteria and/or submission.**

    / 3 pts

    Social History

    **3 to >2 pts**

    **Includes all of the required following: tobacco use, drug use, alcohol use, marital status, employment status, current/previous occupation, sexual orientation, sexually active, contraceptive use, and living situation.**

    **2 to >1 pts**

    **Includes 10 of the 11 required following: tobacco use, drug use, alcohol use, marital status, employment status, current/previous occupation, sexual orientation, sexually active, contraceptive use, and living situation.**

    **1 to >0 pts**

    **Includes 9 or less of the required information.**

    **0 pts**

    **Missing criteria and/or submission.**

    / 3 pts

    Health Maintenance / Screenings

    **3 to >2 pts**

    **Includes a detailed assessment of immunization status and other health maintenance needs such as age-appropriate screenings and preventive measures Includes an assessment of at least 5 screening tests**

    **2 to >1 pts**

    **Includes a partial assessment of immunization status and health maintenance needs, missing some key components. Includes an assessment of at least 4 screening tests**

    **1 to >0 pts**

    **Includes minimal assessment of immunization status and health maintenance needs, lacking detail. Includes an assessment of at least 3 screening tests**

    **0 pts**

    **Missing criteria and/or submission.**

    / 3 pts

    Physical Examination

    **15 to >8 pts**

    **Includes a minimum of 4 assessments for each body system and assesses at least 5 body systems directed to chief complaint**

    **8 to >3 pts**

    **Includes a minimum of 3 assessments for each body system and assesses at least 4 body systems directed to chief complaint**

    **3 to >0 pts**

    **Includes a minimum of 2 assessments for each body system and assesses at least 4 body systems directed to chief complaint**

    **0 pts**

    **Missing criteria and/or submission.**

    / 15 pts

    Diagnosis

    **5 to >3 pts**

    **Includes a clear outline of the accurate principal diagnosis AND lists the remaining diagnoses addressed at the visit (in descending priority)**

    **3 to >1 pts**

    **Includes a clear outline of the accurate diagnoses addressed at the visit but does not list the diagnoses in descending order of priority**

    **1 to >0 pts**

    **Includes 1 differential diagnosis for the principal diagnosis**

    **0 pts**

    **Missing criteria and/or submission.**

    / 5 pts

    Differential Diagnosis

    **5 to >3 pts**

    **Includes at least 3 differential diagnoses for the principal diagnosis**

    **3 to >1 pts**

    **Includes at least 2 differential diagnoses for the principal diagnosis**

    **1 to >0 pts**

    **Includes at least 1 differential diagnoses for the principal diagnosis**

    **0 pts**

    **Missing criteria and/or submission.**

    / 5 pts

    ICD 10 Coding

    **3 to >2 pts**

    **Correctly includes all ICD-10 codes relevant to the diagnoses addressed at the visit**

    **2 to >1 pts**

    **Correctly includes most ICD-10 codes relevant to the diagnoses addressed at the visit**

    **1 to >0 pts**

    **Includes some ICD-10 codes relevant to the diagnoses addressed at the visit**

    **0 pts**

    **Missing criteria and/or submission.**

    / 3 pts

    Pharmacologic treatment plan

    **5 to >3 pts**

    **Includes a detailed pharmacologic treatment plan for each of the diagnoses listed under “assessment”. The plan includes ALL of the required following: drug name, dose, route, frequency, duration and cost as well as education related to pharmacologic agent. If the diagnosis is a chronic problem, student includes instructions on currently prescribed medications as above.**

    **3 to >1 pts**

    **Includes a detailed pharmacologic treatment plan for each of the diagnoses listed under “assessment”. The plan includes 4 of the required following 7: the drug name, dose, route, frequency, duration and cost as well as education related to pharmacologic agent. If the diagnosis is a chronic problem, student includes instructions on currently prescribed medications as above.**

    **1 to >0 pts**

    **Includes a detailed pharmacologic treatment plan for each of the diagnoses listed under “assessment”. The plan includes less than 4 of the information:**

    **0 pts**

    **Missing criteria and/or submission.**

    / 5 pts

    Diagnostic / Lab Testing

    **3 to >2 pts**

    **Includes appropriate diagnostic/lab testing 100% of the time OR acknowledges “no diagnostic testing clinically required at this time”**

    **2 to >1 pts**

    **Includes appropriate diagnostic/lab testing 50% of the time OR acknowledges “no diagnostic testing clinically required at this time”**

    **1 to >0 pts**

    **Includes appropriate diagnostic testing less than 50% of the time.**

    **0 pts**

    **Missing criteria and/or submission.**

    / 3 pts

    Education

    **3 to >2 pts**

    **Includes at least 3 strategies to promote and develop skills for managing their illness and at least 3 self-management methods on how to incorporate healthy behaviors into their lives.**

    **2 to >1 pts**

    **Includes at least 2 strategies to promote and develop skills for managing their illness and at least 2 self-management methods on how to incorporate healthy behaviors into their lives.**

    **1 to >0 pts**

    **Includes at least 1 strategies to promote and develop skills for managing their illness and at least 1 self-management methods on how to incorporate healthy behaviors into their lives**

    **0 pts**

    **Missing criteria and/or submission.**

    / 3 pts

    Anticipatory Guidance

    **3 to >2 pts**

    **Includes at least 3 primary prevention strategies (related to age/condition (i.e. immunizations, pediatric and pre-natal milestone anticipatory guidance)) and at least 2 secondary prevention strategies (related to age/condition (i.e. screening))**

    **2 to >1 pts**

    **Includes at least 2 primary prevention strategies (related to age/condition (i.e. immunizations, pediatric and pre-natal milestone anticipator guidance)) and at least 2 secondary prevention strategies (related to age/condition (i.e. screening))**

    **1 to >0 pts**

    **Includes at least 1 primary prevention strategies (related to age/condition (i.e. immunizations, pediatric and pre-natal milestone anticipatory guidance)) and at least 1 secondary prevention strategies (related to age/condition (i.e. screening))**

    **0 pts**

    **Missing criteria and/or submission.**

    / 3 pts

    Follow Up Plan

    **2 to >1 pts**

    **Includes recommendation for follow up, including time frame (i.e. x # of days/weeks/months)**

    **1 to >0 pts**

    **Includes recommendation for follow up, but does not include time frame (i.e. x # of days/weeks/months)**

    **0 pts**

    **Missing criteria and/or submission.**

    / 2 pts

    Prescription

    **3 to >2 pts**

    **Prescription includes all required components: patient information, date, drug name, dose, route, frequency, quantity to be dispensed, refills, and provider’s signature and credentials**

    **2 to >1 pts**

    **Prescription includes most required components, but is missing 1-2 elements such as quantity to be dispensed or refills**

    **1 to >0 pts**

    **Prescription is missing 3 or more required components such as patient information, date, or provider’s signature**

    **0 pts**

    **Missing criteria and/or submission.**

    / 3 pts

    Writing Mechanics, Citations, and APA Style

    **3 to >2 pts**

    **Effectively uses the literature and other resources to inform their work. Exceptional use of citations and extended referencing. APA style is correct, and writing is free of grammar and spelling errors.**

    **2 to >1 pts**

    **Moderately use the literature and other resources to inform their work. Moderately use of citations and extended referencing. APA style and writing mechanics need more precision and attention to detail.**

    **1 to >0 pts**

    **Ineffectively uses the literature and other resources to inform their work. Ineffectively use of citations and extended referencing. APA style and writing mechanics need serious attention.**

    **0 pts**

    **Missing criteria and/or submission.**

    / 3 pts

    Total Points: 0

    – [\
    \
    SOAPNoteTemplate2.docx](https://www.sweetstudy.com/files/soapnotetemplate2-docx-10161057 "SOAPNoteTemplate2.docx")

    – 2 years ago

  • [Solved] Mod.2 Assignment Part 1/APA STYLE/Turnitin-Plagiarism FREE-Pharm

    ✓ Verified Academic Solution Available

    Executive Solution Overview

    _**Begin Research for Your Drug Projects**_ Drug of choice: Ferrous Sulfate Begin a bibliography review on your drug of choice (Ferrous Sulfate) Review a minimum of five academic articles and map out your research on your drug of choice by creating a table that includes the information you found on …

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    Assignment Prompt & Instructions

    _**Begin Research for Your Drug Projects**_

    Drug of choice: Ferrous Sulfate

    Begin a bibliography review on your drug of choice (Ferrous Sulfate) Review a minimum of five academic articles and map out your research on your drug of choice by creating a table that includes the information you found on your drug of choice including the author, the date, article name, location of the published source, and page number. (Information gathered is to be used in a assignment later)

    – 2 years ago

  • [Solved] nur502

    ✓ Verified Academic Solution Available

    Executive Solution Overview

    – 2 years ago **files (1)** – ## Module2Discussion2.docx **## Module2Discussion2.docx** **Hematopoietic:** J.D. is a 37 years old white woman who presents to her gynecologist complaining of a 2-month history of intermenstrual bleeding, menorrhagia, increased urinary frequency, mild incontinence, ext…

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    Assignment Prompt & Instructions

    – 2 years ago

    **files (1)**

    – ## Module2Discussion2.docx

    **## Module2Discussion2.docx**

    **Hematopoietic:** J.D. is a 37 years old white woman who presents to her gynecologist complaining of a 2-month history of intermenstrual bleeding, menorrhagia, increased urinary frequency, mild incontinence, extreme fatigue, and weakness. Her menstrual period occurs every 28 days and lately there have been 6 days of heavy flow and cramping. She denies abdominal distension, back-ache, and constipation. She has not had her usual energy levels since before her last pregnancy.

    **Past Medical History (PMH):**
    Upon reviewing her past medical history, the gynecologist notes that her patient is a G5P5with four pregnancies within four years, the last infant having been delivered vaginally four months ago. All five pregnancies were unremarkable and without delivery complications. All infants were born healthy. Patient history also reveals a 3-year history of osteoarthritis in the left knee, probably the result of sustaining significant trauma to her knee in an MVA when she was 9 years old. When asked what OTC medications she is currently taking for her pain and for how long she has been taking them, she reveals that she started taking ibuprofen, three tablets each day, about 2.5 years ago for her left knee. Due to a slowly progressive increase in pain and a loss of adequate relief with three tablets, she doubled the daily dose of ibuprofen. Upon the recommendation from her nurse practitioner and because long-term ibuprofen use can cause peptic ulcers, she began taking OTC omeprazole on a regular basis to prevent gastrointestinal bleeding. Patient history also reveals a 3-year history of HTN for which she is now being treated with a diuretic and a centrally acting antihypertensive drug. She has had no previous surgeries.

    **Case Study Questions**

    1. Name the contributing factors on J.D that might put her at risk to develop iron deficiency anemia.

    2. Within the case study, describe the reasons why J.D. might be presenting constipation and or dehydration.

    3. Why Vitamin B12 and folic acid are important on the erythropoiesis? What abnormalities their deficiency might cause on the red blood cells?

    4. The gynecologist is suspecting that J.D. might be experiencing iron deficiency anemia.
    In order to support the diagnosis, list and describe the clinical symptoms that J.D. might have positive for Iron deficiency anemia.

    5. If the patient is diagnosed with iron deficiency anemia, what do you expect to find as signs of this type of anemia? List and describe.

    6. Labs results came back for the patient. Hb 10.2 g/dL; Hct 30.8%; Ferritin 9 ng/dL; red blood cells are smaller and paler in color than normal. Research list and describe for appropriate recommendations and treatments for J.D.

    **## Module2Discussion2.docx**

    **Hematopoietic:** J.D. is a 37 years old white woman who presents to her gynecologist complaining of a 2-month history of intermenstrual bleeding, menorrhagia, increased urinary frequency, mild incontinence, extreme fatigue, and weakness. Her menstrual period occurs every 28 days and lately there have been 6 days of heavy flow and cramping. She denies abdominal distension, back-ache, and constipation. She has not had her usual energy levels since before her last pregnancy.

    **Past Medical History (PMH):**
    Upon reviewing her past medical history, the gynecologist notes that her patient is a G5P5with four pregnancies within four years, the last infant having been delivered vaginally four months ago. All five pregnancies were unremarkable and without delivery complications. All infants were born healthy. Patient history also reveals a 3-year history of osteoarthritis in the left knee, probably the result of sustaining significant trauma to her knee in an MVA when she was 9 years old. When asked what OTC medications she is currently taking for her pain and for how long she has been taking them, she reveals that she started taking ibuprofen, three tablets each day, about 2.5 years ago for her left knee. Due to a slowly progressive increase in pain and a loss of adequate relief with three tablets, she doubled the daily dose of ibuprofen. Upon the recommendation from her nurse practitioner and because long-term ibuprofen use can cause peptic ulcers, she began taking OTC omeprazole on a regular basis to prevent gastrointestinal bleeding. Patient history also reveals a 3-year history of HTN for which she is now being treated with a diuretic and a centrally acting antihypertensive drug. She has had no previous surgeries.

    **Case Study Questions**

    1. Name the contributing factors on J.D that might put her at risk to develop iron deficiency anemia.

    2. Within the case study, describe the reasons why J.D. might be presenting constipation and or dehydration.

    3. Why Vitamin B12 and folic acid are important on the erythropoiesis? What abnormalities their deficiency might cause on the red blood cells?

    4. The gynecologist is suspecting that J.D. might be experiencing iron deficiency anemia.
    In order to support the diagnosis, list and describe the clinical symptoms that J.D. might have positive for Iron deficiency anemia.

    5. If the patient is diagnosed with iron deficiency anemia, what do you expect to find as signs of this type of anemia? List and describe.

    6. Labs results came back for the patient. Hb 10.2 g/dL; Hct 30.8%; Ferritin 9 ng/dL; red blood cells are smaller and paler in color than normal. Research list and describe for appropriate recommendations and treatments for J.D.