Tommy Acker ihuman case study: Pediatric Fillable Soap Note Template

May 30, | nursing, med, NURS, Paper

Tommy Acker ihuman case study: Pediatric Fillable Soap Note Template
Tommy Acker ihuman case study: Pediatric Fillable Soap Note Template
You will complete a Comprehensive SOAP note on the approved Pediatric SOAP Note template based on the findings of the iHuman case – then major research and discussion of the disease process are presented.

This case study should be a summative evaluation supported by a minimum of 5 evidence-based articles.

Evaluation of the case study should be no more than 3-4 substantive paragraphs. A minimum of five evidence-based sources (in addition to your text) should be used for your case study.

Course texts will not count as a scholarly source; if using data from websites you must go back to the literature source for the information-no secondary sources are allowed, ie, Medscape, UptoDate, etc. Tommy Acker ihuman case study: Pediatric Fillable Soap Note Template.

This week, complete the iHuman case titled ”Tommy Acker V3”.
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STUDENT NAME:
DATE OF ASSIGNMENT:

Patient Initials: Tommy Acker
Date of Encounter:
 

Sex: Male
Age/DOB/Place of Birth: 26 months old
2/5/2017

SUBJECTIVE
Tommy Acker ihuman case study: Pediatric Fillable Soap Note Template

Historian: Mother
Present Concerns/CC: “Stomach ache” (abdominal pain)

Child Profile: Listless and ill appearing 26-month-old, male with a history of Downs’s syndrome and …. The mother states … as other children. She states that he is clumsy. He is always tripping, falling, or bumping into things as if he does not see that it is there. None of his … in him requiring medical attention. She states that he is normally … and does not require much else. He does not go to day care and lives at home with his two siblings and mother. His mother works and their neighbors or mother’s boyfriend babysit the children. Tommy Acker ihuman case study: Pediatric Fillable Soap Note Template.

HPI:
Onset: xx days ago
Location/Radiation: xxx pain
Duration: xxx over 2 days
Character: xxx
Aggravating factors: xxx
Relieving Factors: none
Timing: constant
Severity: severe
Tommy, a 26-month-old male with Down syndrome, was brought into the ED by his mother who reports he has been “complaining” of… days, had emesis x 1, is lethargic, sweati…is grossly distended with significant epigastric bruising, in a distribution that is atypical for a fall. It is firm to Tommy Acker ihuman case study: Pediatric Fillable Soap Note Template… tenderness. A reducible 2.0-cm umbilical hernia is present.
 

Medications: None currently.

PMH: Normal pregnancy and no complications noted at birth.
 
Allergies: None
Medication Intolerances:  None
Chronic Illnesses/Major traumas: Atrioventricular septal defect, tra….

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… thus, meeting more than two criteria for SIRS.
3.       Child Abuse: Act of Commission (T74.12XA): According to the Centers for Disease Control (CDC), physical, … and neglect (CDC, 2019). Neglect is defined as the failure to meet a child’s basic physical and emotional needs, including food, shelter, clothing, education, and access to medical care (CDC, 2019). Physical abuse is intentionally using physical force that may result in injury, such as, hitting, kicking, burning, or shaking of a child (CDC, 2019). Emotional abuse refers to the behaviors that harm a child’s self-worth or emotional well-being, such as shaming, rejection, or withholding love or affection (CDC, 2019). Abuse can come from …factors. In the situation with T.A., the mother was neglecting her children to be able to provide basic needs for them, while depriving them of education and exposing them to physical abuse from her boyfriend. Tommy’s injuries also do not match up to the stories his mother is reporting, and she seemed to take some time to bring him in to be evaluated and became defensive when possible questions that may point toward abuse were asked. Tommy Acker ihuman case study: Pediatric Fillable Soap Note Template.
4.       Volvulus (K56.2): Volvulus can vary in presentation from vague, recurrent gastrointestinal discomfort to sudden onset of an acute abdomen with associated shock symptoms (Saxena, 2017). It may present in any age group and is not associated with traumatic injury. More often it occurs as a result of a congenital malrotation of the midgut (Saxena, 2017).

PLAN including education

Initial resuscitation and stabilization protocol:
1.       Assess airway, circulation and breathing. Provide oxygen for hypoxia.
2.       Place on …, continuous pulse oximetry, and monitor vital signs.
3.       Place two …. as they are needed.
4.       Complete Primary (airway, breathing, circulation, disability, and exposure) and secondary (head-toe exam) surveys (Kaplan, 2018). Tommy Acker ihuman case study: Pediatric Fillable Soap Note Template.
T.A. is a child that is critically-ill. He will require further testing such as a … with contrast and an emergent surgical consult. He will also be admitted to the intensive care unit for further management. It is important to contact child protective services, police, and social-work personnel as needed.
 

 
NSG 6435 Week 7 W7 Assignment 1
Assignment 1: Comprehensive Case Study
General Guidelines for Comprehensive Case Study – Week 7 Assignment 1
Your case study should not be just a SOAP note of a patient encounter—it should be a comprehensive evaluation of an iHuman patient case.
You will complete a Comprehensive SOAP note on the approved Pediatric SOAP Note template based on the findings of the iHuman case – then major research and discussion of the disease process are presented.
This case study should be a summative evaluation supported by a minimum of 5 evidence-based articles.
Evaluation of the case study should be no more than 3-4 substantive paragraphs.A minimum of five evidence-based sources (in addition to your text) should be used for your case study.
Course texts will not count as a scholarly source; if using data from websites you must go back to the literature source for the information-no secondary sources are allowed, ie, Medscape, UptoDate, etc.
This week, complete the iHuman case titled “Tommy Acker, Child Abuse”.Click here for information on how to access and navigate Tommy Acker ihuman case study: Pediatric Fillable Soap Note Template.
Name your SOAP note document SU_NSG6435_W7_A1_lastname_firstinitial.doc
i-Human
i-Human is an interactive cloud based system that provides comprehensive learning that
integrates clinical experience.The i-Human system helps students develop patient assessment
and diagnostic reasoning skills at various levels of education.Students will receive online
guidance, feedback, and coaching during the learning process.
Student Login Instructions for Tommy Acker ihuman case study: Pediatric Fillable Soap Note Template
Logging in to i-Human:
Log on at:
http://toolmanagement.next.ecollege.com/tools/thirdparty/blti.ed?launch=LS:iHuman:Patients
Next Steps:
1) If you were unable to attend a Student Orientation Webinar, please watch this introduction
video: https://vimeo.com/185046053/228aea3fc9
2) Additional tutorial videos can be found on the i-Human home screen under the title “Player
Screencast Tutorials”
3) After attending the webinar or viewing the tutorial you are ready for your first practice
case.
4) The i-Human Student Support Center (link on the home screen under the videos) is a
resource for our most frequently asked questions.The Student Manual is also located here.
5) If you are having any issues that are not answered through the webinars, videos or support
center, you can email: [email protected] Tommy Acker ihuman case study: Pediatric Fillable Soap Note Template.
 
PEDIATRIC FILLABLE SOAP NOTE TEMPLATE
STUDENT NAME:
Patient Initials:
 
Sex:
 
SUBJECTIVE
Historian:
Present Concerns/CC:
DATE OF ASSIGNMENT:
Date of Encounter:
 
Age/DOB/Place of Birth:
 
Reason given by the patient for seeking medical care “in quotes”
Child Profile:  (Sexual History (If appropriate); ADLs (age appropriate); Safety Practices; Changes in daycare/school/after-school care; Tommy Acker ihuman case study: Pediatric Fillable Soap Note Template.
Sports/physical activity; Developmental Hx)
 
HPI: (must include all components – OLD CARTS)
 
Medications: (List with reason for meds)
 
PMH:
Allergies:
 
Medication Intolerances:
 
Chronic Il nesses/Major traumas:
 
Hospitalizations/Surgeries:
 
Immunizations: Tommy Acker ihuman case study: Pediatric Fillable Soap Note Template.
 
1 | P E D I A T R I C   S O A P   N O T E
 
PEDIATRIC FILLABLE SOAP NOTE TEMPLATE
 
Family History  (please identify al  immediate family)
 
 
Social History (Education level, occupational history, current living situation/partner/marital status, substance use/abuse, ETOH, tobacco, Tommy Acker ihuman case study: Pediatric Fillable Soap Note Template.
and marijuana.  Safety status)
 
Review of Systems (ROS)
 
General
 
Skin
 
Eyes
 
Ears
 
Nose/Mouth/Throat
 
Breast
 
Heme/Lymph/Endo
 
2 | P E D I A T R I C   S O A P   N O T E
Cardiovascular
 
Respiratory
 
Gastrointestinal
 
Genitourinary/Gynecological
 
Musculoskeletal
 
Neurological
 
Psychiatric
PEDIATRIC FILLABLE SOAP NOTE TEMPLATE
OBJECTIVE  (plot height/weight/head circumference along with noting percentiles)
Attach growth chart
 
Weight
 
Height
Temp
 
Pulse
BP
 
Resp
 
 
OBJECTIVE (Physical Examination)
 
General Appearance and parent–child interaction
 
Skin
 
HEENT
 
Cardiovascular
 
Respiratory
 
Gastrointestinal
 
Breast
 
Genitourinary
 
Musculoskeletal
 
3 | P E D I A T R I C   S O A P   N O T E
 
PEDIATRIC FILLABLE SOAP NOTE TEMPLATE
 
Neurological
 
Psychiatric
 
In-house Lab Tests – document tests (results or pending)
 
Pediatric/Adolescent Assessment Tools (Ages & Stages, etc) with results and rationale
For adolescents (HEADSSSVG Assessment)
 
ASSESSMENT (Diagnosis – 3 Differentials and Primary)
     Include at least three differential diagnoses with ICD-10 codes.  (Includes Primary dx and 2
differentials) Tommy Acker ihuman case study: Pediatric Fillable Soap Note Template.
     Document Evidence based Rationale for ROS and each differential with pertinent
positives and negatives
     Primary diagnosis
     Is #1 on list of differentials
     Evidence for primary diagnosis should be supported in the Subjective and Objective
exams.
1)
 
2)
 
3)
 
4 | P E D I A T R I C   S O A P   N O T E
 
PEDIATRIC FILLABLE SOAP NOTE TEMPLATE
PLAN including education
PLAN including education
     Plan:  Treatment plan should be for the Primary Diagnosis and based on EB literature.
     Include EB rationale for all aspects of your treatment plan:
     Vaccines administered this visit
     Vaccine administration forms given
     Medication-amounts and mg/kg for medications
     Laboratory tests ordered
     Diagnostic tests ordered
     Patient education including preventive care and anticipatory guidance
     Non-medication treatments
Fol ow-up appointment with detailed plan of  f/u
 
*ALL references must be Evidence Based (EB)
 
5 | P E D I A T R I C   S O A P   N O T E
Pediatric_Fillable_SOAP_Note_Template–
growth_chart
Tommy Acker ihuman case study: Pediatric Fillable Soap Note Template

nursing care plan for ear infection essay

May 30, | nursing, med, NURS, Paper

nursing care plan for ear infection essay
Holistic Assessment of an Adult Ear Using an Otoscope (Observation) and Palpation
Assessment or examination of the ear for appropriate and correct diagnosis uses the techniques of inspection or observation as well as palpation. Because there are internal structures in the ear, the inspection aspect is facilitated by the use of an otoscope (Ball et al., 2019). This paper presents some of the findings that may come out of the examination of an adult patient’s ears.
Table 1: Examination of an adult ear

Part/ Procedure
Findings

Inspection of the external ear structures (including the auricle, tragus, and lobule)
·       The gross structure of the ears including the lobules of the auricles appears the same in size and shape on both sides.
·       The tragus and antitragus do not appear swollen or inflamed bilaterally.
·       There are no piercings bilaterally on the lobule, the helix, or the tragus.
·       The intertragic notch shows no sign or evidence of otorrhea or ear discharge bilaterally.
·       There are no visible lesions bilaterally on both ears, and the color of the ears is homogeneous with the rest of the body.
·       There is no discoloration on both sides.

Palpation of the external structures of the ear (including the auricle and mastoid process)
·       The auricle, the helix, the tragus, and antitragus all do not show any tenderness or swelling bilaterally.
·       Also, there are no masses that are palpable bilaterally.
·       On palpation of the mastoid process, the patient denies any tenderness on both sides.
·       The auricle feels soft and flexible bilaterally on palpation.

Bilateral inspection of the external auditory canal using the otoscope
·       The patient denies any discomfort when the otoscope is inserted in the external auditory canal on both sides.
·       Inspection of the external auditory canal reveals a clear canal with just a little cerumen that is brown in color.
·       There is no otorrhea visible bilaterally.
·       The canal walls are smooth with no evidence of nodules or inconsistencies bilaterally.

Bilateral inspection of the tympanic membranes
·       The tympanic membrane shows no perforation or sclerosis on both sides.
·       There are also no visible fluid levels behind the tympanic membrane bilaterally.
·       However, there are bubbles that are visible on otoscopy on the right side.
·       There is no cholesteatoma in the attic area of the membrane bilaterally.
·       The tympanic membrane shows a visible bulge and demonstrates reduced mobility on pneumatic otoscopy on the right side too.
·       The tympanic membrane on the left is round, smooth, and has no bulge or any other visible abnormality.

A common ear disorder or abnormal finding discoverable in an ear assessment
Acute otitis media (AOM)
·       In this condition, the tympanic membrane shows an opaque reaction to light and may also bulge.
·       Fluid may be demonstrated in the middle ear through otoscopy and visible through the tympanic membrane.
·       There is inflammation shown by redness of the tympanic membrane and the patient may have fever and tenderness on inserting the otoscope.
·       The fluid behind the tympanic membrane may also be pus at times (Hammer & McPhee, 2018).

Nursing Diagnoses for AOM in Adults

A health promotion nursing diagnosis for AOM
A risk nursing diagnosis for AOM
A collaborative problem or actual nursing diagnosis for AOM

Readiness for enhanced learning on the prevention of acute otitis media
Risk for developing intra-temporal abscess if AOM is left untreated
Risk for complications of intracranial and intra-temporal conditions

 
 
 
References
Ball, J., Dains, J.E., Flynn, J.A., Solomon, B.S., & Stewart, R.W. (2019). Seidel’s guide to physical examination: An interprofessional approach, 9th ed. Elsevier.
Hammer, D.G., & McPhee, S.J. (Eds). (2018). Pathophysiology of disease: An introduction to clinical medicine, 8th ed. McGraw-Hill Education.
 
OTOSCOPE Assignment
Ear Assessment and appropriate nursing diagnoses (Do assessment on an adult) In the boxes, describe your findings. Do not use the word “Normal” or approximations of it, such as N/A, expected, etc. State what you found using terminology appropriate for the area. See the textbook for appropriate wording. If there are no signs or symptoms of any problems, for instance, it would be appropriate to write: Denies tenderness, pain, and paresthesia; no lesions or breakdown observed. No evidence of pathology noted. Then proceed to describe what you assess in terms of observation, (auscultation and percussion are not used in ear assessments) and palpation. Weber and Kelley’s textbook has a helpful guide with pictures and verbiage you may find helpful: Assessment Guide 17-1, in the chapter on ear assessment (note especially the textbook verbiage in the center and right columns.) You may use textbook terminology in this class because it is expected. Many videos are also available to assist you. There is one on Blackboard in the current module, and YouTube has a number of them as well. Do not use the work of other students. That is plagiarism, and our detection program will flag it. If confirmed it will mean the grade of F in the class: It isn’t worth it!
Current Symptoms: Ears Assessment Findings External Ear Structures 1. Inspect the auricle, tragus, and lobule for size and shape, bilaterally. Describe bilateral position, lesions/discoloration, and discharge. Auricle is 6.5 cm vertical dimension, rounded, and light brown flesh-colored bilaterally (in keeping with client’s skin color.) No lesions or tenderness bilaterally. Tragus is triangular, non-tender, no lesions, color consistent with auricle, no piercings bilaterally. Lobules are attached, with one piercing bilaterally, nontender without lesions bilaterally.
2. Palpate the auricle and mastoid process bilaterally. Describe findings, including symptomatology or tenderness if they are present. Auricle and mastoid process are without lesions, and client denies tenderness; auricle is flexible and soft.
Otoscopic Examination 3. Bilaterally inspect the external auditory canal with the otoscope for discharge, color and consistency of cerumen, color and consistency of canal walls, and any nodules. (Address each of these items bilaterally.) Auditory canals: smooth walls, slightly pink color, no nodules bilaterally. Dark brown cerumen is present in the right canal, left canal has no visible cerumen.
4. Inspect and describe the tympanic membranes bilaterally, using the otoscope, for color and shape, and The tympanic membranes on the right cannot be visualized due to brown cerumen blocking the ear canal; the left tympanic membrane appears round, smooth, and pearly gray. The cone-shaped reflection of the otoscope light is landmarks. reflected at 7 O’clock.
5. List a common ear disorder or abnormal assessment finding that would be discoverable in an ear or hearing assessment on a hypothetical patient. (You may include the medical diagnosis, but it is not required. You may select a problem that has not yet been diagnosed since this is a very realistic scenario—often nurses are the one who discover problems first and then refer the client.) The patient has been diagnosed with a basal cell carcinoma on his right auricle, but has not yet been treated. Surgical removal and use of fluorouracil cream are planned by dermatologist beginning next week. Skin lesion is on the very top of the auricle and extends over both the front and back of it. The lesion is rough/uneven, 6 mm at largest diameter, and has a small amount of yellow discharge dried around the edges. The edges of the lesion appear “rolled”” and pink. The lesion is non-tender. Patient states he never has used sunscreen. Adapted from Weber