Download and analyze the case study for this week. Create a SOAP note for disease prevention, health promotion, and acute care of the patient in the clinical case. Your care plan should be based on current evidence and nursing standards of care.
Visit the online library and research for current scholarly evidence (no older than 5 years) to support your nursing actions. In addition, consider visiting government sites such as the CDC, WHO, AHRQ, Healthy People 2020. Provide a detailed scientific rationale justifying the inclusion of this evidence in your plan.
Next determine the ICD-10 classification (diagnoses). The International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-10-CM) is the official system used in the United States to classify and assign codes to health conditions and related information.
Download the access codes.
Download the SOAP template to help you design a holistic patient care plan. Utilize the SOAP guidelines to assist you in creating your SOAP note and building your plan of care. You are expected to develop a comprehensive SOAP note based on the given assessment, diagnosis, and advanced nursing interventions. Reflect on what you have learned about care plans through independent research and peer discussions and incorporate the knowledge that you have gained into your patient’s care plan. If the information is not in the provided scenario please consider it normal for SOAP note purposes, if it is abnormal please utilize what you know about the disease process and write what you would expect in the subjective and objective areas of your note.
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Introduction:
As a medical professor, it is important to educate and train students in creating comprehensive care plans for patients. In this assignment, students are required to analyze a case study and create a SOAP note for disease prevention, health promotion, and acute care of the patient. This care plan should be based on current evidence and nursing standards of care. Additionally, students are expected to determine the ICD-10 classification (diagnoses), and provide a detailed scientific rationale justifying the inclusion of evidence in their plan.
1. How should students approach creating a SOAP note for disease prevention, health promotion, and acute care of the patient in the clinical case?
Students should first gather information about the patient’s medical history, current symptoms, and any relevant risk factors for diseases. Based on this information, students can identify potential health concerns that require preventive measures or acute care interventions. The SOAP note should follow the standard format of subjective, objective, assessment, and plan sections. The subjective section should include the patient’s symptoms and any relevant medical history. The objective section should include physical examination findings and diagnostic test results. The assessment section should include the diagnosis or potential diagnoses based on the subjective and objective data. Finally, the plan section should outline appropriate interventions for disease prevention and health promotion, as well as acute care interventions if necessary.
2. How can students justify including scholarly evidence in their care plan, and where can they find this evidence?
Students should search for current scholarly evidence (no older than 5 years) to support their nursing actions. They can find this evidence in online databases such as PubMed or CINAHL, as well as by visiting government sites such as the CDC, WHO, AHRQ, and Healthy People 2020. The scientific rationale for including this evidence in the care plan should be based on the strength and relevance of the evidence to the patient’s specific health concerns. For example, if the evidence suggests that a particular screening test is effective in preventing a certain disease, this test may be included in the care plan for the patient if they are at risk for that disease.
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