Advance Nursing Practice

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Patient Setting:
28-year-old female presents to the clinic with a 2 day history of frequency, burning and pain upon
urination; increased lower abdominal pain and vaginal discharge over the past week.
HPI
Complains of urinary symptoms similar to those of previous urinary tract infections (UTIs) which started
approximately 2 days ago; also experiencing severe lower abdominal pain and noted brown fouls
smelling discharge after having unprotected intercourse with her former boyfriend.
PMH
Recurrent UTIs (3 this year); gonorrhea X2, chlamydia X 1; Gravida IV Para III
Past Surgical History
Tubal ligation 2 years ago.
Family/Social History
Family: Single; history of multiple male sexual partners; currently lives with new boyfriend and 3
children.
Social: Denies smoking, alcohol and drug use.
Medication History
None
Trimethoprim (TOM)/ Sulfamethoxazole (SMX) -Rash
ROS
Last pap 6 months ago, Denies breast discharge. Positive for Urine looking dark.
Physical exam
BP 100/80,
HR 80,
RR 16,
T 99.7 F,
Wt 120,
Ht 5’ 0”
Gen: Female in moderate distress.
HEENT: WNL.
Cardio: Regular rate and rhythm normal S1 and S2.
Chest: WNL.
Abd: soft, tender, increased suprapubic tenderness.
GU: Cervical motion tenderness, adnexal tenderness, foul smelling vaginal drainage.
Rectal: WNL.

Assignment 2: Comprehensive Plan of Care and Paper

Overview/Description:

You have been provided with case studies in Week 4 and Week 5 that focused on genitourinary, and musculoskeletal disorders. You will pick one of these cases to analyze and create a comprehensive plan of care for acute/chronic care, disease prevention, and health promotion for that patient and disorder. Your care plan should be based on current best practices and supported with citations from current literature, such as systematic reviews, published practice guidelines, standards of care from specialty organizations, and other research based resources. In addition, you will provide a detailed scientific rationale that justifies the inclusion of this evidence in your plan. Your paper should adhere to APA format for title page, headings, citations, and references. The paper should be no more than 3 pages typed excluding title page and references.

Criteria:

  • SOAP note
  • Evaluation of priority diagnosis
  • Facilitators and barriers to disorder management

Submit your document to the W4 Assignment 2 Dropbox by Tuesday, July 18, 2017.

Assignment 2 Grading Criteria

Maximum Points

Introduction

The submission included a general introduction to the priority diagnosis.

10

Subjective Data

The submission included the patient’s interpretation of current medical problem. It included chief complaint, history of present illness, current medications and reason prescribed, past medical history, family history, and review of systems.

15

Objective Data

The submission included the measurements and observations obtained by the nurse practitioner. It included head to toe physical examination as well as laboratory and diagnostic testing results.

15

Assessment

The submission included at least three priority diagnoses. Each diagnosis was supported by documentation in subjective and objective notes and free of essential omissions. All diagnoses were documented using acceptable terminologies and current ICD-10 codes.

20

Plan of Care

Plan included diagnostic and therapeutic (pharmacologic and non-pharmacologic) management as well as education and counseling provided. The plan was supported by evidence/guidelines, and the follow-up plans were noted.

25

Evaluation of Priority Diagnosis

The plan chose the priority diagnosis for the patient and differentiated the disorder from normal development. Discussed the physical and psychological demands the disorder places on the patient and family and key concepts to discuss with them. Identified key interdisciplinary team personnel needed and how this team will provide care to achieve optimal disorder management and outcomes.

25

Facilitators and Barriers

The submission interpreted facilitators and barriers to optimal disorder management and outcomes and strategies to overcome the identified barriers.

20

Conclusion

The submission included what should be taken away from this assignment.

10

APA/Style/Format

The submission was free of grammatical, spelling, or punctuation errors. Citations and references were written in correct APA Style.
Utilized proper format with coversheet, header.

10

Total

150

APA..FNP?MD viewpoint

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