MN552 SOAP Note: Advanced Practice Nursing Assessment
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.
- Click here for the written guide for the Comprehensive SOAP Note.Unit 4 Discussion 1
Critical Thinking and Diagnostic Reasoning
Please select one of the following case studies and complete the chart. Please review audio-videos, PowerPoint presentations, and assigned chapters to assist with this Assignment. You are expected to role play the selected scenario with a family member to gather necessary data to complete the chart. For each person described in the following situations, discuss the developmental/age, socioeconomic, ethical considerations, and cross-cultural considerations that should be considered during the gathering of subjective and objective data, and the provision of health care. Discuss any additional information that might be needed before a judgment or diagnosis can be made. Submit the completed chart to the Discussion Board by Friday at 11:59 p.m.
1. A. E. is a 35-year-old African American female, and is 5 months pregnant presenting to the office today for a routine prenatal visit. She complains that her neck feels swollen and that she has been feeling nervous and tired. She also complains about the heat, excessive sweating, and how she “can’t seem to get cool during these summer months.” She attributes all these complaints to her pregnancy.
2. J. L. is a 55-year-old Caucasian female who had a CVA within the past week. J. L. is easily frustrated, anxious, fearful, and her speech is slurred. She needs verbal cuing for any task she is asked to carry out. She eats only food on the left side of the tray and responds only when approached from the left side.
Components of
assessment
Subjective
Diagnostic Reasoning
(list key questions — use PQRSTU pneumonic)
Objective
Normal vs.
abnormal findings
(must note pertinent body systems to be examined)
Differential
diagnoses
(list 3)
Nurses diagnosis (list 1)
List relevant labs and
diagnostic studies (if any)
Normal Differential Abnormal Findings Nurses Diagnosis Developmental/age considerations:
Socioeconomic considerations:
Cross-cultural considerations:
Ethical considerations:
Additional info needed to formulate actual diagnosis:
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