Discussion Topic: Pediatric Soap Note  (tension headache in a 13 years old adolescent)

Requirements

– The discussion must address the topic

– Rationale must be provided mainly in the differential diagnosis

– Use at least 600 words (no included 1st page or references in the 600 words)

– May use examples from your nursing practice

– Formatted and cited in current APA 7

– Use 3 academic sources, not older than 5 years. Not Websites are allowed.

– Plagiarism is NOT permitted

I have attached the SOAP note template, a SOAP note sample, and the rubric.

please follow all direction 

 

Case Study: A 25-year-old presented to the labor and delivery unit with complaints of uterine cramping and lower back pain. The client denied any vaginal bleeding and had a history of preterm birth at 32 weeks (about 7 and a half months) gestation with her last pregnancy. The baby from that pregnancy is three years old has no developmental issues. The client’s gestational age is 30 weeks (about 7 months). She is O+, and all other lab values are normal. No evidence of sexually transmitted infections (STI’s).

(Group Beta Strep is missing from the labs and most often is obtained at 35 – 37 weeks (about 8 and a half months) gestation. Without this information, it is often determined to treat the patient anyway, to protect a premature baby from the risk.)

• What additional information should the nurse obtain from the client?
• What nursing intervention is most appropriate in this situation?
• What screening tests should be obtained to determine the risk for preterm labor?
• If the client is in preterm labor, what medications would the nurse expect to be ordered, and what are the priorities for the nurse to assess post-administration? (Include dose, side effects and expected outcomes of the medication).

  

Purpose: Analyze and apply critical thinking skills in the psychopathology of mental health patients and provide treatment and health promotion while applying evidence-based research.

Scenario:

Kel is a 42-year-old certified public accountant (CPA) who dreams each year that she will board a cruise ship the day after Tax Day and go somewhere, anywhere, except Portsmouth, Virginia. Each year the dream, like the ocean, ebbs and flows, but this year she is not even going to think about such a “ridiculous idea.” In fact, she does not even have the energy to dream; getting out of bed and preparing to go to work is simply too labor intensive. 

Each evening Kel retires to bed with a lack of energy to complete her normal tasks such as readying her clothes for work and making a lunch. She lacks the energy to shop in the evening; consequently, she eats mostly crackers and canned soup. She is not hungry, and her scale reflects this. She has lost 15 pounds over the last 2 months. She does not attend to her makeup or clothes; she finds both too taxing. The clothes she selects are drab and not ironed. At work she makes no effort to talk with her co-workers and does not initiate new contacts with clients. The normal work of filing taxes and writing reports, which she used to enjoy, are overwhelming, and she feels too disorganized to complete them. Telephone calls and e-mail messages from friends are ignored. Attendance at work is spotty.

Sue, her sister, becomes alarmed with Kel’s unanswered telephone calls and e-mails. Worried, she decides to visit her sister at home. She finds the apartment unclean and in disarray. Kel is unkempt, disheveled, and looks sad. Her voice is monotone and flat. Kel tells Sue that she feels “sad and hopeless. Nothing is ever going to change. I am a bad person and I can’t even do my work right. Although I sleep for many hours, I am still tired all the time.” Sue is alarmed at the changes in her sister and arranges for Kel to visit a health care worker at the medical clinic.

Questions:

Remember to answer these questions from your textbooks and NP guidelines. At all times, explain your answers. 

Describe the presenting problems.

Generate a primary and differential diagnosis using the DSM5 and ICD 10 codes.

Formulate and prioritize a treatment plan. 

Identify and discuss appropriate screening instruments for a patient who has suicidal ideation.