Tag: Nursing

  • [Solved] Week 7 Final Project

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    Executive Solution Overview

    see attachments. – ## Finalprojectinstructions.pdf – ## FinalProjectWeek7.pdf **## Finalprojectinstructions.pdf** The paper should only be 2-3 pages long and should be written as a formal paper. Information must be in complete sentences (not phrases). Include all aspects of the bullet points in your…

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    Assignment Prompt & Instructions

    see attachments.

    – ## Finalprojectinstructions.pdf

    – ## FinalProjectWeek7.pdf

    **## Finalprojectinstructions.pdf**

    The paper should only be 2-3 pages long and should be written as a formal paper.
    Information must be in complete sentences (not phrases). Include all aspects of the bullet points
    in your paper. The paper is about how you can compile information into a complete but concise
    document, very similar to a resource or protocol that you would have in clinic when looking up
    information about a certain diagnosis. It must be in paragraph form where you are using topic
    headers for each paragraph; this is NOT a SOAP note.

    **## FinalProjectWeek7.pdf**

    Dysfunctional/Abnormal Uterine Bleeding (DUB/AUB)

    Scenario:

    A 29-year-old patient presents in the clinic with bleeding in between menses. The onset of

    menarche was age 14 and she has had regular monthly menses. For the past 2 months, she has

    been spotting between menses. She is not on any hormonal birth control, and she uses condoms

    occasionally to prevent pregnancy and STIs. She is currently with a new partner of 6 months, and

    she hasn’t been tested for STIs with this partner. She is in the clinic because she is concerned

    about why she has been spotting in between menses. She is considering possibly regulating her

    menses. Upon history taking and physical exam, you do not notice anything abnormal. You

    suspect this is a case of dysfunctional uterine bleeding.

    Based on your working diagnosis, patient’s HPI, and your physical assessment, create a 3- to 5-

    minute video and a 2- to 4-page write-up discussing the following information:

    • Definition of DUB/AUB: What is this condition? Why is this important to address?

    • Prevalence and risk factors

    • DUB/AUB can be a risk of developing what types of health complications?

    • Presentation

    • Pathophysiology

    • Physical assessment and testing to confirm diagnosis

    • Provide at least one differential diagnosis and an exam and/or lab test to rule out this

    diagnosis.

    • If a patient is hesitant about taking medication or intervening now, how long can she

    continue to “watchfully observe” her situation before an intervention must occur?

    • Treatment or management of dysfunctional uterine bleeding for a patient who is currently

    not planning a pregnancy

    • Treatment or management of dysfunctional uterine bleeding for a patient who is currently

    planning a pregnancyYour video can be informative while your write-up will be more detailed.
    Be creative with the

    video. There are many ways to complete this portion of the assignment.

    Below are some examples of potential ideas to help you brainstorm:

    • Create an explainer video with animations and voiceover using Biteable, Canva,

    Powtoon, Animaker, or any other software platform.

    • Create a voiceover PowerPoint presentation or use Panopto to record your screen while

    you present your slides and your narration.

    Your write-up and your video must include at least two scholarly sources that are not from your

    textbook nor any standard government or medical websites.

    • Scholarly sources must be peer-reviewed articles.

    • Do not write this paper in a SOAP format.

    • You don’t need to rewrite the prompt in your paper.

    • Be sure you use APA Style and include headings and subheadings and an introduction

    and conclusion.

    • Reference and use in-text citations properly according to APA Style.

    • Be sure to include a title page and a reference list for the write-up and the video.

    **## FinalProjectWeek7.pdf**

    Dysfunctional/Abnormal Uterine Bleeding (DUB/AUB)

    Scenario:

    A 29-year-old patient presents in the clinic with bleeding in between menses. The onset of

    menarche was age 14 and she has had regular monthly menses. For the past 2 months, she has

    been spotting between menses. She is not on any hormonal birth control, and she uses condoms

    occasionally to prevent pregnancy and STIs. She is currently with a new partner of 6 months, and

    she hasn’t been tested for STIs with this partner. She is in the clinic because she is concerned

    about why she has been spotting in between menses. She is considering possibly regulating her

    menses. Upon history taking and physical exam, you do not notice anything abnormal. You

    suspect this is a case of dysfunctional uterine bleeding.

    Based on your working diagnosis, patient’s HPI, and your physical assessment, create a 3- to 5-

    minute video and a 2- to 4-page write-up discussing the following information:

    • Definition of DUB/AUB: What is this condition? Why is this important to address?

    • Prevalence and risk factors

    • DUB/AUB can be a risk of developing what types of health complications?

    • Presentation

    • Pathophysiology

    • Physical assessment and testing to confirm diagnosis

    • Provide at least one differential diagnosis and an exam and/or lab test to rule out this

    diagnosis.

    • If a patient is hesitant about taking medication or intervening now, how long can she

    continue to “watchfully observe” her situation before an intervention must occur?

    • Treatment or management of dysfunctional uterine bleeding for a patient who is currently

    not planning a pregnancy

    • Treatment or management of dysfunctional uterine bleeding for a patient who is currently

    planning a pregnancyYour video can be informative while your write-up will be more detailed.
    Be creative with the

    video. There are many ways to complete this portion of the assignment.

    Below are some examples of potential ideas to help you brainstorm:

    • Create an explainer video with animations and voiceover using Biteable, Canva,

    Powtoon, Animaker, or any other software platform.

    • Create a voiceover PowerPoint presentation or use Panopto to record your screen while

    you present your slides and your narration.

    Your write-up and your video must include at least two scholarly sources that are not from your

    textbook nor any standard government or medical websites.

    • Scholarly sources must be peer-reviewed articles.

    • Do not write this paper in a SOAP format.

    • You don’t need to rewrite the prompt in your paper.

    • Be sure you use APA Style and include headings and subheadings and an introduction

    and conclusion.

    • Reference and use in-text citations properly according to APA Style.

    • Be sure to include a title page and a reference list for the write-up and the video.

    **## Finalprojectinstructions.pdf**

    The paper should only be 2-3 pages long and should be written as a formal paper.
    Information must be in complete sentences (not phrases). Include all aspects of the bullet points
    in your paper. The paper is about how you can compile information into a complete but concise
    document, very similar to a resource or protocol that you would have in clinic when looking up
    information about a certain diagnosis. It must be in paragraph form where you are using topic
    headers for each paragraph; this is NOT a SOAP note.

    **## FinalProjectWeek7.pdf**

    Dysfunctional/Abnormal Uterine Bleeding (DUB/AUB)

    Scenario:

    A 29-year-old patient presents in the clinic with bleeding in between menses. The onset of

    menarche was age 14 and she has had regular monthly menses. For the past 2 months, she has

    been spotting between menses. She is not on any hormonal birth control, and she uses condoms

    occasionally to prevent pregnancy and STIs. She is currently with a new partner of 6 months, and

    she hasn’t been tested for STIs with this partner. She is in the clinic because she is concerned

    about why she has been spotting in between menses. She is considering possibly regulating her

    menses. Upon history taking and physical exam, you do not notice anything abnormal. You

    suspect this is a case of dysfunctional uterine bleeding.

    Based on your working diagnosis, patient’s HPI, and your physical assessment, create a 3- to 5-

    minute video and a 2- to 4-page write-up discussing the following information:

    • Definition of DUB/AUB: What is this condition? Why is this important to address?

    • Prevalence and risk factors

    • DUB/AUB can be a risk of developing what types of health complications?

    • Presentation

    • Pathophysiology

    • Physical assessment and testing to confirm diagnosis

    • Provide at least one differential diagnosis and an exam and/or lab test to rule out this

    diagnosis.

    • If a patient is hesitant about taking medication or intervening now, how long can she

    continue to “watchfully observe” her situation before an intervention must occur?

    • Treatment or management of dysfunctional uterine bleeding for a patient who is currently

    not planning a pregnancy

    • Treatment or management of dysfunctional uterine bleeding for a patient who is currently

    planning a pregnancyYour video can be informative while your write-up will be more detailed.
    Be creative with the

    video. There are many ways to complete this portion of the assignment.

    Below are some examples of potential ideas to help you brainstorm:

    • Create an explainer video with animations and voiceover using Biteable, Canva,

    Powtoon, Animaker, or any other software platform.

    • Create a voiceover PowerPoint presentation or use Panopto to record your screen while

    you present your slides and your narration.

    Your write-up and your video must include at least two scholarly sources that are not from your

    textbook nor any standard government or medical websites.

    • Scholarly sources must be peer-reviewed articles.

    • Do not write this paper in a SOAP format.

    • You don’t need to rewrite the prompt in your paper.

    • Be sure you use APA Style and include headings and subheadings and an introduction

    and conclusion.

    • Reference and use in-text citations properly according to APA Style.

    • Be sure to include a title page and a reference list for the write-up and the video.

    **## Finalprojectinstructions.pdf**

    The paper should only be 2-3 pages long and should be written as a formal paper.
    Information must be in complete sentences (not phrases). Include all aspects of the bullet points
    in your paper. The paper is about how you can compile information into a complete but concise
    document, very similar to a resource or protocol that you would have in clinic when looking up
    information about a certain diagnosis. It must be in paragraph form where you are using topic
    headers for each paragraph; this is NOT a SOAP note.

    **## FinalProjectWeek7.pdf**

    Dysfunctional/Abnormal Uterine Bleeding (DUB/AUB)

    Scenario:

    A 29-year-old patient presents in the clinic with bleeding in between menses. The onset of

    menarche was age 14 and she has had regular monthly menses. For the past 2 months, she has

    been spotting between menses. She is not on any hormonal birth control, and she uses condoms

    occasionally to prevent pregnancy and STIs. She is currently with a new partner of 6 months, and

    she hasn’t been tested for STIs with this partner. She is in the clinic because she is concerned

    about why she has been spotting in between menses. She is considering possibly regulating her

    menses. Upon history taking and physical exam, you do not notice anything abnormal. You

    suspect this is a case of dysfunctional uterine bleeding.

    Based on your working diagnosis, patient’s HPI, and your physical assessment, create a 3- to 5-

    minute video and a 2- to 4-page write-up discussing the following information:

    • Definition of DUB/AUB: What is this condition? Why is this important to address?

    • Prevalence and risk factors

    • DUB/AUB can be a risk of developing what types of health complications?

    • Presentation

    • Pathophysiology

    • Physical assessment and testing to confirm diagnosis

    • Provide at least one differential diagnosis and an exam and/or lab test to rule out this

    diagnosis.

    • If a patient is hesitant about taking medication or intervening now, how long can she

    continue to “watchfully observe” her situation before an intervention must occur?

    • Treatment or management of dysfunctional uterine bleeding for a patient who is currently

    not planning a pregnancy

    • Treatment or management of dysfunctional uterine bleeding for a patient who is currently

    planning a pregnancyYour video can be informative while your write-up will be more detailed.
    Be creative with the

    video. There are many ways to complete this portion of the assignment.

    Below are some examples of potential ideas to help you brainstorm:

    • Create an explainer video with animations and voiceover using Biteable, Canva,

    Powtoon, Animaker, or any other software platform.

    • Create a voiceover PowerPoint presentation or use Panopto to record your screen while

    you present your slides and your narration.

    Your write-up and your video must include at least two scholarly sources that are not from your

    textbook nor any standard government or medical websites.

    • Scholarly sources must be peer-reviewed articles.

    • Do not write this paper in a SOAP format.

    • You don’t need to rewrite the prompt in your paper.

    • Be sure you use APA Style and include headings and subheadings and an introduction

    and conclusion.

    • Reference and use in-text citations properly according to APA Style.

    • Be sure to include a title page and a reference list for the write-up and the video.

    – 1
    – 2

  • [Solved] PEDS WK6 DB

    ✓ Verified Academic Solution Available

    Executive Solution Overview

    – ## Week6DBQUESTIONS.docx **## Week6DBQUESTIONS.docx** **Week 6 Discussion Part I** **Table 1** **Differential Diagnosis Pediatric Limp** | | | | | | | | | — | — | — | — | — | — | — | | Complete the table. CC limp | | Condition | Age | Pain (+ or -) | Historical Findings | Clinical Fi…

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    Assignment Prompt & Instructions

    – ## Week6DBQUESTIONS.docx

    **## Week6DBQUESTIONS.docx**

    **Week 6 Discussion Part I**

    **Table 1**

    **Differential Diagnosis Pediatric Limp**

    | | | | | | | |
    | — | — | — | — | — | — | — |
    | Complete the table. CC limp |
    | Condition | Age | Pain (+ or -) | Historical Findings | Clinical Findings | Causative Factors | Management |
    | Developmental Dysplasia of Hip | | | | | | |
    | Leg-length Inequality | | | | | | |
    | Juvenile Arthritis | | | | | | |
    | Slipped capital femoral epiphysis (SCFE) | | | | | | |
    | Legg-Calve-Perthes disease | | | | | | |
    | Transient synovitis | | | | | | |
    | Trauma | | | | | | |
    | Neoplasm | | | | | | |
    | Septic arthritis | | | | | | |
    | Acute hematogenous osteomyelitis | | | | | | |

    **Table 2**

    **Differential Diagnosis Pediatric Headaches**

    | | | |
    | — | — | — |
    | Complete the table. |
    | Common Types | Diagnostic Criteria Based on History | Treatment/Management |
    | Pediatric Migraine Headache | | |
    | Tension Headache | | |
    | Chronic Tension Headache | | |
    | Other Differentials: List 3 additional differentials for headache | Characteristics | Management |
    | 1. | | |
    | 2. | | |
    | 3. | | |

    **Table 3**

    **Musculoskeletal Disorders and Sports-Related Injuries**

    | | | | | | | |
    | — | — | — | — | — | — | — |
    | Complete the table. |
    | | Adolescent Idiopathic Scoliosis | Osgood-Schlatter Disease | Meniscal Tear | Quadriceps Contusion | Sprain of MCL | Osteochondritis dissecans |
    | Description | | | | | | |
    | Screening Test? | | | | | | |
    | How do you perform the screening test? | | | | | | |
    | Imaging? | | | | | | |
    | Treatment Plan | | | | | | |

    Jim is a 17-year-old who was brought into the clinic today for a headache. He reports nausea and an increase in stress from school and after-school activities (basketball practice and debate team). His vital signs are within normal limits and his BMI is 24.

    · What more should you know about Jim?

    · What information in your history and exam would be red flags suggestive of secondary or pathologic headaches

    · What education would you provide for Jim and his parents?

    **## Week6DBQUESTIONS.docx**

    **Week 6 Discussion Part I**

    **Table 1**

    **Differential Diagnosis Pediatric Limp**

    | | | | | | | |
    | — | — | — | — | — | — | — |
    | Complete the table. CC limp |
    | Condition | Age | Pain (+ or -) | Historical Findings | Clinical Findings | Causative Factors | Management |
    | Developmental Dysplasia of Hip | | | | | | |
    | Leg-length Inequality | | | | | | |
    | Juvenile Arthritis | | | | | | |
    | Slipped capital femoral epiphysis (SCFE) | | | | | | |
    | Legg-Calve-Perthes disease | | | | | | |
    | Transient synovitis | | | | | | |
    | Trauma | | | | | | |
    | Neoplasm | | | | | | |
    | Septic arthritis | | | | | | |
    | Acute hematogenous osteomyelitis | | | | | | |

    **Table 2**

    **Differential Diagnosis Pediatric Headaches**

    | | | |
    | — | — | — |
    | Complete the table. |
    | Common Types | Diagnostic Criteria Based on History | Treatment/Management |
    | Pediatric Migraine Headache | | |
    | Tension Headache | | |
    | Chronic Tension Headache | | |
    | Other Differentials: List 3 additional differentials for headache | Characteristics | Management |
    | 1. | | |
    | 2. | | |
    | 3. | | |

    **Table 3**

    **Musculoskeletal Disorders and Sports-Related Injuries**

    | | | | | | | |
    | — | — | — | — | — | — | — |
    | Complete the table. |
    | | Adolescent Idiopathic Scoliosis | Osgood-Schlatter Disease | Meniscal Tear | Quadriceps Contusion | Sprain of MCL | Osteochondritis dissecans |
    | Description | | | | | | |
    | Screening Test? | | | | | | |
    | How do you perform the screening test? | | | | | | |
    | Imaging? | | | | | | |
    | Treatment Plan | | | | | | |

    Jim is a 17-year-old who was brought into the clinic today for a headache. He reports nausea and an increase in stress from school and after-school activities (basketball practice and debate team). His vital signs are within normal limits and his BMI is 24.

    · What more should you know about Jim?

    · What information in your history and exam would be red flags suggestive of secondary or pathologic headaches

    · What education would you provide for Jim and his parents?

  • [Solved] Week 6 DB

    ✓ Verified Academic Solution Available

    Executive Solution Overview

    see attachment – ## Week6DB.pdf **## Week6DB.pdf** Case Scenario 1- Complete the chart and answer the case scenario Kelly is a 19-year-old female who comes to your clinic complaining of severe menstrual pain that is usually worse just prior to and during the first two days of her menses. The pain is…

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    Assignment Prompt & Instructions

    see attachment

    – ## Week6DB.pdf

    **## Week6DB.pdf**

    Case Scenario 1- Complete the chart and answer the case scenario

    Kelly is a 19-year-old female who comes to your clinic complaining of severe menstrual pain that is
    usually worse just prior to and during the first two days of her menses. The pain is sometimes so
    severe that she has fainted. She states that defecation can cause severe pain and she therefore
    frequently becomes constipated. She often must miss work when experiencing the severe pain. Her
    periods are heavy and last seven days with a tapering of the bleeding from days 3 to 7. Her BMI is
    23.9 and her VS are all WNL. She is G0 P0.

    Write a brief SOAP note regarding this patient. Make sure to include your answers to these
    questions in your SOAP note.

    1. Subjective:
    a. What other relevant questions should you ask regarding the HPI?
    b. What other medical history questions should you ask?

    Diagnosis Definition Presentation/

    Sign and
    Symptom

    Management

    Bartholin Cyst

    Squamous
    Carcinoma of the
    Vagina

    Adenocarcinoma
    of the Vagina

    Lichen Sclerosus

    Lichen Planus

    Lichen Simplex
    Chronicus

    Vulvodynia

    c. What other social history questions should you ask?
    d. What other family history questions should you ask?

    2. Objective:
    a. Write a detailed focused physical assessment on this patient.
    b. Explain what test(s) you will order and perform, and discuss your rationale for

    ordering and performing each test.
    3. Assessment/ Diagnosis:

    a. What is your presumptive diagnosis? Why?
    b. Any other diagnosis or differential diagnosis you would like to add?

    4. Plan:
    a. How will you manage this patient? What treatment or medication would you prescribe

    and why?
    b. Explain treatment guidelines and side effects including any possible side effects of

    the medication and treatment(s),
    c. What patient education is important to include for this patient? (Consider including

    pharmacological, supplements, and non pharmacological recommendations and
    education)

    d. What is the follow-up plan of care?
    e. Explain complications that can occur if patient does not comply with treatment

    regimen.

    Please refer to evidence-based guidelines to support your decision-making.

    SOAP NOTE FORMAT

    Subjective

    CC:

    HPI:

    Medications:

    Allergies:

    LMP:

    Gyn/OB history:

    PMH:

    Chronic Illness/ Major trauma:

    Family Hx:

    Social Hx:

    ROS

    – List the body systems and provide answers

    – (Don’t forget to include Gyn ROS)

    – You can include questions here that you’d like to ask the patient

    Objective Data

    General- provide findings

    VS

    List body systems- provide findings

    – (Don’t forget Gyn System)

    – (You can include answers here to questions posed in the prompt)

    Include POCT (Point of Care testing) not labs that you will send to the laboratoryAssessment/

    DiagnosisInclude the ICD10 code

    DDX

    Plan

    Diagnostic tests

    Lab Tests

    Treatment

    Medication

    Referrals

    Education

    Health Maintenance

    Follow up

    Prompt Questions

    (You can include answers here that is asked in the prompt)

    **## Week6DB.pdf**

    Case Scenario 1- Complete the chart and answer the case scenario

    Kelly is a 19-year-old female who comes to your clinic complaining of severe menstrual pain that is
    usually worse just prior to and during the first two days of her menses. The pain is sometimes so
    severe that she has fainted. She states that defecation can cause severe pain and she therefore
    frequently becomes constipated. She often must miss work when experiencing the severe pain. Her
    periods are heavy and last seven days with a tapering of the bleeding from days 3 to 7. Her BMI is
    23.9 and her VS are all WNL. She is G0 P0.

    Write a brief SOAP note regarding this patient. Make sure to include your answers to these
    questions in your SOAP note.

    1. Subjective:
    a. What other relevant questions should you ask regarding the HPI?
    b. What other medical history questions should you ask?

    Diagnosis Definition Presentation/

    Sign and
    Symptom

    Management

    Bartholin Cyst

    Squamous
    Carcinoma of the
    Vagina

    Adenocarcinoma
    of the Vagina

    Lichen Sclerosus

    Lichen Planus

    Lichen Simplex
    Chronicus

    Vulvodynia

    c. What other social history questions should you ask?
    d. What other family history questions should you ask?

    2. Objective:
    a. Write a detailed focused physical assessment on this patient.
    b. Explain what test(s) you will order and perform, and discuss your rationale for

    ordering and performing each test.
    3. Assessment/ Diagnosis:

    a. What is your presumptive diagnosis? Why?
    b. Any other diagnosis or differential diagnosis you would like to add?

    4. Plan:
    a. How will you manage this patient? What treatment or medication would you prescribe

    and why?
    b. Explain treatment guidelines and side effects including any possible side effects of

    the medication and treatment(s),
    c. What patient education is important to include for this patient? (Consider including

    pharmacological, supplements, and non pharmacological recommendations and
    education)

    d. What is the follow-up plan of care?
    e. Explain complications that can occur if patient does not comply with treatment

    regimen.

    Please refer to evidence-based guidelines to support your decision-making.

    SOAP NOTE FORMAT

    Subjective

    CC:

    HPI:

    Medications:

    Allergies:

    LMP:

    Gyn/OB history:

    PMH:

    Chronic Illness/ Major trauma:

    Family Hx:

    Social Hx:

    ROS

    – List the body systems and provide answers

    – (Don’t forget to include Gyn ROS)

    – You can include questions here that you’d like to ask the patient

    Objective Data

    General- provide findings

    VS

    List body systems- provide findings

    – (Don’t forget Gyn System)

    – (You can include answers here to questions posed in the prompt)

    Include POCT (Point of Care testing) not labs that you will send to the laboratoryAssessment/

    DiagnosisInclude the ICD10 code

    DDX

    Plan

    Diagnostic tests

    Lab Tests

    Treatment

    Medication

    Referrals

    Education

    Health Maintenance

    Follow up

    Prompt Questions

    (You can include answers here that is asked in the prompt)

  • [Solved] wk6 focused peds soap note

    ✓ Verified Academic Solution Available

    Executive Solution Overview

    – ## wellchildsoapnotetemplate.docx **## wellchildsoapnotetemplate.docx** **Well-child SOAP Note Format** _Demographic Data_ · Age, and gender (must be HIPAA compliant) _Subjective_ · ___-day/week old infant/child accompanied by ___________ and here for a routine well-child/baby check …

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    Assignment Prompt & Instructions

    – ## wellchildsoapnotetemplate.docx

    **## wellchildsoapnotetemplate.docx**

    **Well-child SOAP Note Format**

    _Demographic Data_

    · Age, and gender (must be HIPAA compliant)

    _Subjective_

    · ___-day/week old infant/child accompanied by ___________ and here for a routine well-child/baby check (and vaccines). Any parental concerns/ questions today?

    · Interval Events/History:

    · Nutrition:

    · Elimination:

    · Sleep:

    · Medications:

    · Allergies:

    · Past Medical

    ·

    · Pregnancy and delivery?

    · Surgeries, hospitalizations, or serious illnesses to date?

    · Immunizations?

    · Development: (describe as applicable to age)

    ·

    · Gross motor:

    ·

    · Fine motor:

    · Cognitive:

    · Social/Emotional:

    · Communication:

    · Social History:

    · Smoking in the home?

    · Family life/structure/dynamics? Primary caregivers?

    · Stressors?

    ·  Family History:

    _Objective_ _(Should be a thorough head to toe assessment)_

    · Vital Signs/growth measurements (weight, length, head circumference, BMI, BP, HR, etc. if applicable)

    ·

    · Physical findings listed by body systems, not paragraph form.

    · Highlight abnormal findings

    · Growth Chart Percentages: if applicable

    · Labs/Studies: if applicable

    _Assessment_

    · Well-child visit ICD10 code(s)

    _Plan_

    · Vaccines today:

    · Anticipatory guidance (discussed or covered in the visit)?

    · Health Maintenance

    · Return precautions?

    **## wellchildsoapnotetemplate.docx**

    **Well-child SOAP Note Format**

    _Demographic Data_

    · Age, and gender (must be HIPAA compliant)

    _Subjective_

    · ___-day/week old infant/child accompanied by ___________ and here for a routine well-child/baby check (and vaccines). Any parental concerns/ questions today?

    · Interval Events/History:

    · Nutrition:

    · Elimination:

    · Sleep:

    · Medications:

    · Allergies:

    · Past Medical

    ·

    · Pregnancy and delivery?

    · Surgeries, hospitalizations, or serious illnesses to date?

    · Immunizations?

    · Development: (describe as applicable to age)

    ·

    · Gross motor:

    ·

    · Fine motor:

    · Cognitive:

    · Social/Emotional:

    · Communication:

    · Social History:

    · Smoking in the home?

    · Family life/structure/dynamics? Primary caregivers?

    · Stressors?

    ·  Family History:

    _Objective_ _(Should be a thorough head to toe assessment)_

    · Vital Signs/growth measurements (weight, length, head circumference, BMI, BP, HR, etc. if applicable)

    ·

    · Physical findings listed by body systems, not paragraph form.

    · Highlight abnormal findings

    · Growth Chart Percentages: if applicable

    · Labs/Studies: if applicable

    _Assessment_

    · Well-child visit ICD10 code(s)

    _Plan_

    · Vaccines today:

    · Anticipatory guidance (discussed or covered in the visit)?

    · Health Maintenance

    · Return precautions?

  • [Solved] Nursing Homework

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    – ## ComprehensiveevaluationtemplateNUR650.docx – NUR650clCPE2instructionsandRubric.docx **## ComprehensiveevaluationtemplateNUR650.docx** ![page1image3861729600](https://www.sweetstudy.com/questions/nursing-homework-20921211) **Comprehensive Psychiatric Evaluation Template** **With Psychotherapy No…

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    – ## ComprehensiveevaluationtemplateNUR650.docx

    – NUR650clCPE2instructionsandRubric.docx

    **## ComprehensiveevaluationtemplateNUR650.docx**

    ![page1image3861729600](https://www.sweetstudy.com/questions/nursing-homework-20921211)

    **Comprehensive Psychiatric Evaluation Template**

    **With Psychotherapy Note**

    Encounter date: ________________________

    Patient Initials: ______ Gender: M/F/Transgender ____ Age: _____ Race: _____ Ethnicity ____

    Reason for Seeking Health Care: ______________________________________________

    **HPI**:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

    **SI/HI:** _______________________________________________________________________________

    **Sleep:**_________________________________________
    **Appetite:**\_\_\______________________

    **Allergies**(Drug/Food/Latex/Environmental/Herbal): ___________________________________

    **Current perception of Health**: Excellent Good Fair Poor

    **Psychiatric History:**

    **_Inpatient hospitalizations:_**

    | | | | |
    | — | — | — | — |
    | **_Date_** | **_Hospital_** | **_Diagnoses_** | **_Length of Stay_** |
    | | | | |
    | | | | |

    **_Outpatient psychiatric treatment:_**

    | | | | |
    | — | — | — | — |
    | **_Date_** | **_Hospital_** | **_Diagnoses_** | **_Length of Stay_** |
    | | | | |
    | | | | |

    **_Detox/Inpatient substance treatment:_**

    | | | | |
    | — | — | — | — |
    | **_Date_** | **_Hospital_** | **_Diagnoses_** | **_Length of Stay_** |
    | | | | |
    | | | | |

    **_History of suicide attempts and/or self injurious behaviors:_**\_\_\__________________________________

    **Past Medical History**

    · Major/Chronic Illnesses____________________________________________________

    · Trauma/Injury ___________________________________________________________

    · Hospitalizations __________________________________________________________

    **Past Surgical History**\_\_\_________________________________________________________

    **_Current psychotropic medications:_**

    \_\_\_______________________________________ ________________________________

    \_\_\_______________________________________ ________________________________

    \_\_\_______________________________________ ________________________________

    **_Current prescription medications:_**

    \_\_\_______________________________________ ________________________________

    \_\_\_______________________________________ ________________________________

    \_\_\_______________________________________ ________________________________

    **_OTC/Nutritionals/Herbal/Complementary therapy:_**

    \_\_\_______________________________________ ________________________________

    \_\_\_______________________________________ ________________________________

    **_Substance use_** _:_(alcohol, marijuana, cocaine, caffeine, cigarettes)

    | | | | |
    | — | — | — | — |
    | **_Substance_** | **_Amount_** | **_Frequency_** | **_Length of Use_** |
    | | | | |
    | | | | |
    | | | | |
    | | | | |

    **Family Psychiatric History:** _____________________________________________________

    **Social History**

    **Lives**: Single family House/Condo/ with stairs: ___________
    **Marital Status**:________

    **Education**:____________________________

    **Employment Status**: ______
    **Current/Previous occupation type**: _________________

    **Exposure to:** ___Smoke____ ETOH ____Recreational Drug Use: __________________

    **Sexual Orientation:** _______ Sexual Activity: ____
    **Contraception Use**: ____________

    **Family Composition:** Family/Mother/Father/Alone
    **: _____________________________**

    **Other: (Place of birth, childhood hx, legal, living situations, hobbies, abuse hx, trauma, violence, social network, marital hx):_________________________________**

    **\_\_\______________________________________________________________________**

    **Health Maintenance**

    **Screening Tests (submit with SOAP note): Depression, Anxiety, ADHD, Autism, Psychosis, Dementia**

    **Exposures:**

    **Immunization HX:**

    **Review of Systems (at least 3 areas per system):**

    General:

    HEENT:

    Neck:

    Lungs:

    Cardiovascular:

    Breast:

    GI:

    Male/female genital:

    GU:

    Neuro:

    Musculoskeletal:

    Activity & Exercise:

    Psychosocial:

    Derm:

    Nutrition:

    Sleep/Rest:

    LMP:

    STI Hx:

    **Physical Exam**

    BP________TPR_____ HR: _____ RR: ____Ht. _____ Wt. ______ BMI (
    **percentile**) _____

    General:

    HEENT:

    Neck:

    Pulmonary:

    Cardiovascular:

    Breast:

    GI:

    Male/female genital:

    GU:

    Neuro:

    Musculoskeletal:

    Derm:

    Psychosocial:

    Misc.

    **Mental Status Exam**

    Appearance:

    Behavior:

    Speech:

    Mood:

    Affect:

    Thought Content:

    Thought Process:

    Cognition/Intelligence:

    Clinical Insight:

    Clinical Judgment:

    | |
    | — |
    | **Psychotherapy Note** |
    | **Therapeutic Technique Used:** |
    | **Session Focus and Theme:** |
    | **Intervention Strategies Implemented:** |
    | **Evidence of Patient Response**: |

    **Plan:**

    **Differential Diagnoses**

    **1.**

    **2.**

    **Principal Diagnoses**

    **1.**

    **2.**

    **Plan:**

    **Diagnosis #1**

    **Diagnostic Testing/Screening:**

    **Pharmacological Treatment:**

    **Non-Pharmacological Treatment:**

    **Patient/Family Education:**

    **Referrals:**

    **Follow-up:**

    **Anticipatory Guidance:**

    **Diagnosis #2**

    **Diagnostic Testing/Screening Tool:**

    **Pharmacological Treatment:**

    **Non-Pharmacological Treatment:**

    **Patient/Family Education:**

    **Referrals:**

    **Follow-up:**

    **Anticipatory Guidance:**

    **Signature (with appropriate credentials): __________________________________________**

    **Cite current evidenced based guideline(s) used to guide care (Mandatory)_______________**

    **DEA#: 101010101 STU Clinic LIC# 10000000**

    **Tel: (000) 555-1234 FAX: (000) 555-12222**

    Patient Name: (Initials)______________________________ Age ___________

    Date: _______________

    **RX ______________________________________**

    **SIG:**

    **Dispense**: ___________
    **Refill:** _________________

    **No Substitution**

    **Signature:** ____________________________________________________________

    **Rev. 2272022 LM**

    ## image1.png

    **NUR650clCPE2instructionsandRubric.docx**

    This file is too large to display. [View in new window](https://www.sweetstudy.com/files/nur650clcpe2instructionsandrubric-docx)

    **NUR650clCPE2instructionsandRubric.docx**

    This file is too large to display. [View in new window](https://www.sweetstudy.com/files/nur650clcpe2instructionsandrubric-docx)

    **## ComprehensiveevaluationtemplateNUR650.docx**

    ![page1image3861729600](https://www.sweetstudy.com/questions/nursing-homework-20921211)

    **Comprehensive Psychiatric Evaluation Template**

    **With Psychotherapy Note**

    Encounter date: ________________________

    Patient Initials: ______ Gender: M/F/Transgender ____ Age: _____ Race: _____ Ethnicity ____

    Reason for Seeking Health Care: ______________________________________________

    **HPI**:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

    **SI/HI:** _______________________________________________________________________________

    **Sleep:**_________________________________________
    **Appetite:**\_\_\______________________

    **Allergies**(Drug/Food/Latex/Environmental/Herbal): ___________________________________

    **Current perception of Health**: Excellent Good Fair Poor

    **Psychiatric History:**

    **_Inpatient hospitalizations:_**

    | | | | |
    | — | — | — | — |
    | **_Date_** | **_Hospital_** | **_Diagnoses_** | **_Length of Stay_** |
    | | | | |
    | | | | |

    **_Outpatient psychiatric treatment:_**

    | | | | |
    | — | — | — | — |
    | **_Date_** | **_Hospital_** | **_Diagnoses_** | **_Length of Stay_** |
    | | | | |
    | | | | |

    **_Detox/Inpatient substance treatment:_**

    | | | | |
    | — | — | — | — |
    | **_Date_** | **_Hospital_** | **_Diagnoses_** | **_Length of Stay_** |
    | | | | |
    | | | | |

    **_History of suicide attempts and/or self injurious behaviors:_**\_\_\__________________________________

    **Past Medical History**

    · Major/Chronic Illnesses____________________________________________________

    · Trauma/Injury ___________________________________________________________

    · Hospitalizations __________________________________________________________

    **Past Surgical History**\_\_\_________________________________________________________

    **_Current psychotropic medications:_**

    \_\_\_______________________________________ ________________________________

    \_\_\_______________________________________ ________________________________

    \_\_\_______________________________________ ________________________________

    **_Current prescription medications:_**

    \_\_\_______________________________________ ________________________________

    \_\_\_______________________________________ ________________________________

    \_\_\_______________________________________ ________________________________

    **_OTC/Nutritionals/Herbal/Complementary therapy:_**

    \_\_\_______________________________________ ________________________________

    \_\_\_______________________________________ ________________________________

    **_Substance use_** _:_(alcohol, marijuana, cocaine, caffeine, cigarettes)

    | | | | |
    | — | — | — | — |
    | **_Substance_** | **_Amount_** | **_Frequency_** | **_Length of Use_** |
    | | | | |
    | | | | |
    | | | | |
    | | | | |

    **Family Psychiatric History:** _____________________________________________________

    **Social History**

    **Lives**: Single family House/Condo/ with stairs: ___________
    **Marital Status**:________

    **Education**:____________________________

    **Employment Status**: ______
    **Current/Previous occupation type**: _________________

    **Exposure to:** ___Smoke____ ETOH ____Recreational Drug Use: __________________

    **Sexual Orientation:** _______ Sexual Activity: ____
    **Contraception Use**: ____________

    **Family Composition:** Family/Mother/Father/Alone
    **: _____________________________**

    **Other: (Place of birth, childhood hx, legal, living situations, hobbies, abuse hx, trauma, violence, social network, marital hx):_________________________________**

    **\_\_\______________________________________________________________________**

    **Health Maintenance**

    **Screening Tests (submit with SOAP note): Depression, Anxiety, ADHD, Autism, Psychosis, Dementia**

    **Exposures:**

    **Immunization HX:**

    **Review of Systems (at least 3 areas per system):**

    General:

    HEENT:

    Neck:

    Lungs:

    Cardiovascular:

    Breast:

    GI:

    Male/female genital:

    GU:

    Neuro:

    Musculoskeletal:

    Activity & Exercise:

    Psychosocial:

    Derm:

    Nutrition:

    Sleep/Rest:

    LMP:

    STI Hx:

    **Physical Exam**

    BP________TPR_____ HR: _____ RR: ____Ht. _____ Wt. ______ BMI (
    **percentile**) _____

    General:

    HEENT:

    Neck:

    Pulmonary:

    Cardiovascular:

    Breast:

    GI:

    Male/female genital:

    GU:

    Neuro:

    Musculoskeletal:

    Derm:

    Psychosocial:

    Misc.

    **Mental Status Exam**

    Appearance:

    Behavior:

    Speech:

    Mood:

    Affect:

    Thought Content:

    Thought Process:

    Cognition/Intelligence:

    Clinical Insight:

    Clinical Judgment:

    | |
    | — |
    | **Psychotherapy Note** |
    | **Therapeutic Technique Used:** |
    | **Session Focus and Theme:** |
    | **Intervention Strategies Implemented:** |
    | **Evidence of Patient Response**: |

    **Plan:**

    **Differential Diagnoses**

    **1.**

    **2.**

    **Principal Diagnoses**

    **1.**

    **2.**

    **Plan:**

    **Diagnosis #1**

    **Diagnostic Testing/Screening:**

    **Pharmacological Treatment:**

    **Non-Pharmacological Treatment:**

    **Patient/Family Education:**

    **Referrals:**

    **Follow-up:**

    **Anticipatory Guidance:**

    **Diagnosis #2**

    **Diagnostic Testing/Screening Tool:**

    **Pharmacological Treatment:**

    **Non-Pharmacological Treatment:**

    **Patient/Family Education:**

    **Referrals:**

    **Follow-up:**

    **Anticipatory Guidance:**

    **Signature (with appropriate credentials): __________________________________________**

    **Cite current evidenced based guideline(s) used to guide care (Mandatory)_______________**

    **DEA#: 101010101 STU Clinic LIC# 10000000**

    **Tel: (000) 555-1234 FAX: (000) 555-12222**

    Patient Name: (Initials)______________________________ Age ___________

    Date: _______________

    **RX ______________________________________**

    **SIG:**

    **Dispense**: ___________
    **Refill:** _________________

    **No Substitution**

    **Signature:** ____________________________________________________________

    **Rev. 2272022 LM**

    ## image1.png

    **NUR650clCPE2instructionsandRubric.docx**

    This file is too large to display. [View in new window](https://www.sweetstudy.com/files/nur650clcpe2instructionsandrubric-docx)

    **## ComprehensiveevaluationtemplateNUR650.docx**

    ![page1image3861729600](https://www.sweetstudy.com/questions/nursing-homework-20921211)

    **Comprehensive Psychiatric Evaluation Template**

    **With Psychotherapy Note**

    Encounter date: ________________________

    Patient Initials: ______ Gender: M/F/Transgender ____ Age: _____ Race: _____ Ethnicity ____

    Reason for Seeking Health Care: ______________________________________________

    **HPI**:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

    **SI/HI:** _______________________________________________________________________________

    **Sleep:**_________________________________________
    **Appetite:**\_\_\______________________

    **Allergies**(Drug/Food/Latex/Environmental/Herbal): ___________________________________

    **Current perception of Health**: Excellent Good Fair Poor

    **Psychiatric History:**

    **_Inpatient hospitalizations:_**

    | | | | |
    | — | — | — | — |
    | **_Date_** | **_Hospital_** | **_Diagnoses_** | **_Length of Stay_** |
    | | | | |
    | | | | |

    **_Outpatient psychiatric treatment:_**

    | | | | |
    | — | — | — | — |
    | **_Date_** | **_Hospital_** | **_Diagnoses_** | **_Length of Stay_** |
    | | | | |
    | | | | |

    **_Detox/Inpatient substance treatment:_**

    | | | | |
    | — | — | — | — |
    | **_Date_** | **_Hospital_** | **_Diagnoses_** | **_Length of Stay_** |
    | | | | |
    | | | | |

    **_History of suicide attempts and/or self injurious behaviors:_**\_\_\__________________________________

    **Past Medical History**

    · Major/Chronic Illnesses____________________________________________________

    · Trauma/Injury ___________________________________________________________

    · Hospitalizations __________________________________________________________

    **Past Surgical History**\_\_\_________________________________________________________

    **_Current psychotropic medications:_**

    \_\_\_______________________________________ ________________________________

    \_\_\_______________________________________ ________________________________

    \_\_\_______________________________________ ________________________________

    **_Current prescription medications:_**

    \_\_\_______________________________________ ________________________________

    \_\_\_______________________________________ ________________________________

    \_\_\_______________________________________ ________________________________

    **_OTC/Nutritionals/Herbal/Complementary therapy:_**

    \_\_\_______________________________________ ________________________________

    \_\_\_______________________________________ ________________________________

    **_Substance use_** _:_(alcohol, marijuana, cocaine, caffeine, cigarettes)

    | | | | |
    | — | — | — | — |
    | **_Substance_** | **_Amount_** | **_Frequency_** | **_Length of Use_** |
    | | | | |
    | | | | |
    | | | | |
    | | | | |

    **Family Psychiatric History:** _____________________________________________________

    **Social History**

    **Lives**: Single family House/Condo/ with stairs: ___________
    **Marital Status**:________

    **Education**:____________________________

    **Employment Status**: ______
    **Current/Previous occupation type**: _________________

    **Exposure to:** ___Smoke____ ETOH ____Recreational Drug Use: __________________

    **Sexual Orientation:** _______ Sexual Activity: ____
    **Contraception Use**: ____________

    **Family Composition:** Family/Mother/Father/Alone
    **: _____________________________**

    **Other: (Place of birth, childhood hx, legal, living situations, hobbies, abuse hx, trauma, violence, social network, marital hx):_________________________________**

    **\_\_\______________________________________________________________________**

    **Health Maintenance**

    **Screening Tests (submit with SOAP note): Depression, Anxiety, ADHD, Autism, Psychosis, Dementia**

    **Exposures:**

    **Immunization HX:**

    **Review of Systems (at least 3 areas per system):**

    General:

    HEENT:

    Neck:

    Lungs:

    Cardiovascular:

    Breast:

    GI:

    Male/female genital:

    GU:

    Neuro:

    Musculoskeletal:

    Activity & Exercise:

    Psychosocial:

    Derm:

    Nutrition:

    Sleep/Rest:

    LMP:

    STI Hx:

    **Physical Exam**

    BP________TPR_____ HR: _____ RR: ____Ht. _____ Wt. ______ BMI (
    **percentile**) _____

    General:

    HEENT:

    Neck:

    Pulmonary:

    Cardiovascular:

    Breast:

    GI:

    Male/female genital:

    GU:

    Neuro:

    Musculoskeletal:

    Derm:

    Psychosocial:

    Misc.

    **Mental Status Exam**

    Appearance:

    Behavior:

    Speech:

    Mood:

    Affect:

    Thought Content:

    Thought Process:

    Cognition/Intelligence:

    Clinical Insight:

    Clinical Judgment:

    | |
    | — |
    | **Psychotherapy Note** |
    | **Therapeutic Technique Used:** |
    | **Session Focus and Theme:** |
    | **Intervention Strategies Implemented:** |
    | **Evidence of Patient Response**: |

    **Plan:**

    **Differential Diagnoses**

    **1.**

    **2.**

    **Principal Diagnoses**

    **1.**

    **2.**

    **Plan:**

    **Diagnosis #1**

    **Diagnostic Testing/Screening:**

    **Pharmacological Treatment:**

    **Non-Pharmacological Treatment:**

    **Patient/Family Education:**

    **Referrals:**

    **Follow-up:**

    **Anticipatory Guidance:**

    **Diagnosis #2**

    **Diagnostic Testing/Screening Tool:**

    **Pharmacological Treatment:**

    **Non-Pharmacological Treatment:**

    **Patient/Family Education:**

    **Referrals:**

    **Follow-up:**

    **Anticipatory Guidance:**

    **Signature (with appropriate credentials): __________________________________________**

    **Cite current evidenced based guideline(s) used to guide care (Mandatory)_______________**

    **DEA#: 101010101 STU Clinic LIC# 10000000**

    **Tel: (000) 555-1234 FAX: (000) 555-12222**

    Patient Name: (Initials)______________________________ Age ___________

    Date: _______________

    **RX ______________________________________**

    **SIG:**

    **Dispense**: ___________
    **Refill:** _________________

    **No Substitution**

    **Signature:** ____________________________________________________________

    **Rev. 2272022 LM**

    ## image1.png

    **NUR650clCPE2instructionsandRubric.docx**

    This file is too large to display. [View in new window](https://www.sweetstudy.com/files/nur650clcpe2instructionsandrubric-docx)

    – 1
    – 2

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