NAPRx/CNPR Exam -WITH 160 Questions & Answers-2024-2025.docx, Exams of Nursing

Download NAPRx/CNPR Exam -WITH 160 Questions & Answers-2024-2025.docx and more Exams Nursing in PDF only on Docsity! Chamberlain college of nursing NR509- week 3 SOAP Note final-complete 2024-2025 Initials: TJ Age: 28 Gender: Female Height Weight BP HR RR Temp SPO2 Pain Allergie s 170cm 88kg 139/ 87 82 16 98.9F 99% Medication: Penicillin (rash/ hives) Food: none Environment: Cats, dust (asthma flares up, itchy, watery eyes, sneezing) History of Present Illness (HPI) Chief Complaint (CC) Headache CC is a BRIEF statement identifying why the patient is here - in the patient’s own words - for instance "headache", NOT "bad headache for 3 days”. Sometimes a patient has more than one complaint. For example: If the patient presents with cough and sore throat, identify which is the CC and which may be an associated symptom Onset 5 days ago Location Pain is located at the crown and back of head. Duration Intermittent- daily-lasts for 1-2hrs per episode. Characteristics Dull headache, non- radiating, associated with neck pain Aggravating Factors Movement of head Relieving Factors Tylenol- improved pain to 3/10 ,rest Treatment No other treatment Current Medications: Include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products. Medication (Rx, OTC, or Homeopathic) Dosage Frequency Length of Time Used Reason for Use Proventil 2 puffs PRN for asthma PRN Rescue inhaler for asthma exacerbation Flovent Patient unaware of exact dosage BID Daily Mainenence for Asthma Tylenol 2- regular strength tabs Once a day Once a day for 5 days For headache Advil 200mg PRN PRN For menstrual cramps N/A Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. S: Subjective Information the patient or patient representative told you Chamberlain college of nursing Past Medical History (PMHx) – Includes but not limited to immunization status (note date of last tetanus for all adults), past major illnesses, hospitalizations, and surgeries. Depending on the CC, more info may be needed. Chamberlain college of nursing Chamberlain college of nursing O: Objective Information gathered during the physical examination by inspection, palpation, auscultation, and palpation. If unable to assess a body system, write “Unable to assess”. Document pertinent positive and negative assessment findings. Chamberlain college of nursing Body System Positive Findings Negative Findings General Skin Click or tap here to enter text. Decreased sensation of bilateral feet and inspected skin darkening on the neck. Patient is alert and oriented, pleasant. normal stature while sitting on the exam table, dressed appropriately, and well groomed. In no acute distress and maintains eye contact during examination. Neg inspection for wounds, rash, or lesions HEENT Respiratory Visual acuity: Right eye is 20/40 and Left eye is 20/20. Click or tap here to enter text. Needed to add, the fundoscopic exam- positive for cotton wool bodies. Neg for Papilledema. Head: no trauma, round, and normocephalic. Ears- intact no hearing issues. Pupils are equal, round, and reactive to light. Nose: sense of smell intact, sense of taste: intact, Respirations are 16, patient chest rise symmetrical, no respiratory distress noted, patient spo2 =99% on room air. Neuro Cardiovascular Decreased sensation in bilateral feet (bottom soles) Click or tap here to enter text. Abstract thinking, attention span, comprehension,general knowledge, judgment, memory, vocabulary, articulation, 12 cranial nerves, optic and oculomotor nerves, extraocular eye movements, weber test, Rinne test, gait, graphesthesia, stereognosis all within normal limits. Click or tap here to enter text. Musculoskeletal Click or tap here to enter text. Gait is balanced and normal. Gastrointestinal Click or tap here to enter text. Click or tap here to enter text. Chamberlain college of nursing I e l l Chamberlain college of nursing Acetaminophen Don’t give muscle relaxer (dangerous) 650mg Every 6hrs PRN Headache Is the lowest cost recommended treatment for acute headache (Papadakis, McPhee, & Bernstein, 2019). Continue home meds Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. N/A Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. N/A Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. N/A Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Referral/Consults: Refer to an opthamologist Rationale/Citation Patient complains of blurry vision and headaches when reading or studying. Snellen eye chart results show that right and left eye visual acuity differs (Goadsby et al, 2019). Education: Due to a normal neurological exam, and a dull headache pain that does not escalate and relieved by OTC Tylenol, I will educate patient to continue headache treatment with Tylenol and to follow up if symptoms worsen. Rationale/Citation Tylenol for treatment for acute headache (Papadakis, McPhee, & Bernstein, 2019). Follow Up: Indicate when patient should return to clinic and provide detailed instructions indicating if the patient should return sooner than scheduled or seek attention elsewhere. Follow up at the clinic in 1 week if not better. If symptoms of headache worsen or sever headache, call 911 in case of an emergency and seek medical attention. Rationale/Citation According to Goadsby, et al., (2019), after treatment has been initiated, follow-up care is essential to identify whether progress has been made against the headache complaint. References Include at least one evidence-based peer-reviewed journal article which relates to this case. Use the correct APA 6th edition formatting. Goadsby PJ, Jameson J, Fauci AS, Kasper DL, Hauser SL, Longo DL, Loscalzo J. (2019). Harrison's principles of internal medicine: Headache, 20ed. New York, NY: McGraw-Hill. Retrieved from: http://accessmedicine.mhmedical.com.chamberlainuniversity.idm.oclc.org/ content.aspx? bookid=2129&sectionid=192011003. Chamberlain college of nursing Maxine A. Papadakis, Stephen J. McPhee, Jennifer Bernstein. (2019). Quick Medical Diagnosis & Treatment: Headache, acute New York, NY: McGraw-Hill. Retrieved from: http://accessmedicine.mhmedical.com.chamberlainuniversity.idm.oclc.org/ content.aspx? bookid=2566&sectionid=206884926. Accessed September 21, 2019.