SOAP note – abdominal pain in the LRQ – HA W9 DT1
Type of document Essay
1 Page Double Spaced
Subject area Nursing
Academic Level Ph. D.
Given the following scenario, you will note an incomplete assessment.
Based on the information you have, make an impression of what you think is the client’s problem(s). For example, you may think that the client is heart failure.
Ask yourself what additional subjective and objective data you will need to confirm that diagnosis. Include this information in the scenario. For example, give a lab results that will be indicative of heart failure.
What are the possible differential diagnoses for this client?
Defend your diagnosis or diagnoses with documentation from required readings, pathophysiology book; nurse practitioner’s protocols found in books and journals, and professional journal articles.
Give a rationale for your contribution to the management plan.
At the end of the SOAP note, insert the references you used into a master reference list using the APA format (this will enable your classmate to use your references for further study or research).
Every student should make at least two comments in developing data for the diagnoses.
Every student should make at least one comment on two students’ comments. Indicate whether you agree or disagree; give justification and documentation for your comments.
Every student must contribute to the management plan. Focus the plan on non-medication treatments, the diagnostic plan, and your teaching plan. Each student will contribute at least two comments to the plan.
You are the FNP making rounds at the nursing home. The client is a 70-year-old white female. She is being seen for a complaint of abdominal pain in the LRQ, she describe the pain as sharp and experiences N & V with pain. She is unrelieved with her PRN medications. She reports the pain is worse after meals. She has been a resident in the nursing home for nearly six years. She has been a widow for 10 years and has two children (a 50-year-old son and 47-year-old daughter) and five grandchildren. They live in different counties within the state. She is a retired elementary teacher with over forty-five years of practice. She has a long history of HTN, DMII, Obesity, and arthritis of the knee. Her v/s are B/P 150/88, P: 84, R: 23, T: 102, Weight: 186 Height: 5’5” She is awake, alert, and oriented X 3. She is resting quietly in her bed without any apparent distress or pain. Skin: w/d. Lungs: Clear. Heart: No abnormal sounds heard. No murmurs.
** ALL REFERENCES MUST BE APA FORMAT AND WITHIN THE LAST 5 YEARS OF PUBLICATION.
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