NUR 600 Assignment 11.2: Writing a SOAP Note

ST Thomas University NUR 600 Assignment 11.2: Writing a SOAP Note– Step-By-Step Guide

This guide will demonstrate how to complete the ST Thomas University NUR 600 Assignment 11.2: Writing a SOAP Note  assignment based on general principles of academic writing. Here, we will show you the A, B, Cs of completing an academic paper, irrespective of the instructions. After guiding you through what to do, the guide will leave one or two sample essays at the end to highlight the various sections discussed below.

How to Research and Prepare for NUR 600 Assignment 11.2: Writing a SOAP Note                   

Whether one passes or fails an academic assignment such as the ST Thomas University NUR 600 Assignment 11.2: Writing a SOAP Note  depends on the preparation done beforehand. The first thing to do once you receive an assignment is to quickly skim through the requirements. Once that is done, start going through the instructions one by one to clearly understand what the instructor wants. The most important thing here is to understand the required format—whether it is APA, MLA, Chicago, etc.

After understanding the requirements of the paper, the next phase is to gather relevant materials. The first place to start the research process is the weekly resources. Go through the resources provided in the instructions to determine which ones fit the assignment. After reviewing the provided resources, use the university library to search for additional resources. After gathering sufficient and necessary resources, you are now ready to start drafting your paper.

How to Write the Introduction for NUR 600 Assignment 11.2: Writing a SOAP Note                   

The introduction for the ST Thomas University NUR 600 Assignment 11.2: Writing a SOAP Note is where you tell the instructor what your paper will encompass. In three to four statements, highlight the important points that will form the basis of your paper. Here, you can include statistics to show the importance of the topic you will be discussing. At the end of the introduction, write a clear purpose statement outlining what exactly will be contained in the paper. This statement will start with “The purpose of this paper…” and then proceed to outline the various sections of the instructions.

How to Write the Body for NUR 600 Assignment 11.2: Writing a SOAP Note                   

After the introduction, move into the main part of the NUR 600 Assignment 11.2: Writing a SOAP Note assignment, which is the body. Given that the paper you will be writing is not experimental, the way you organize the headings and subheadings of your paper is critically important. In some cases, you might have to use more subheadings to properly organize the assignment. The organization will depend on the rubric provided. Carefully examine the rubric, as it will contain all the detailed requirements of the assignment. Sometimes, the rubric will have information that the normal instructions lack.

Another important factor to consider at this point is how to do citations. In-text citations are fundamental as they support the arguments and points you make in the paper. At this point, the resources gathered at the beginning will come in handy. Integrating the ideas of the authors with your own will ensure that you produce a comprehensive paper. Also, follow the given citation format. In most cases, APA 7 is the preferred format for nursing assignments.

How to Write the Conclusion for NUR 600 Assignment 11.2: Writing a SOAP Note                   

After completing the main sections, write the conclusion of your paper. The conclusion is a summary of the main points you made in your paper. However, you need to rewrite the points and not simply copy and paste them. By restating the points from each subheading, you will provide a nuanced overview of the assignment to the reader.

How to Format the References List for NUR 600 Assignment 11.2: Writing a SOAP Note                   

The very last part of your paper involves listing the sources used in your paper. These sources should be listed in alphabetical order and double-spaced. Additionally, use a hanging indent for each source that appears in this list. Lastly, only the sources cited within the body of the paper should appear here.

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Sample Answer for NUR 600 Assignment 11.2: Writing a SOAP Note

Patient Information:

Initials: D.P

Age: 23 years

Sex: Male

Race: African American

Subjective History

CC: “Regular headaches.”

HPI:

D.P is a 23-year-old AA male patient who presents with complaints of headaches that began eight days ago. He states that the headaches are intermittent and diffuse all over the head. The pain occurs for about 10-30 minutes. The headache is described as a throbbing pain that has the greatest intensity and pressure above the eyes. He states that the pain spreads to the nose, cheekbones, and jaw. The headache is aggravated by activity and bending over and, to some extent, relieved by rest and taking Tylenol. He denies experiencing nausea, vomiting, photophobia, or phonophobia associated with the headache. He rates the headache as 5/10 on the pain scale. D.P. reports that the headache often interferes with his activities.

Current Medications: OTC Motrin 400 mg PRN to alleviate headaches.

Allergies: Allergic to smoke and air sprays, causing sneezing. No known drug allergies.

PMHx: D.P. has a history of Chronic sinusitis.

Social Hx: D.P. is an intern at an Insurance firm, and he graduated four months ago with a Bachelor’s in Finance. He lives in the college hostels while in school and with his parents and two younger siblings on holidays. His hobbies include reading novels, writing articles, and painting. He is financed by his two parents and gets some money from his part-time job. K.M. admits taking alcohol, 3-4 beers on weekends, but denies smoking or using other illicit drugs.

Family Hx:  Paternal grandfather had pancreatic cancer. Father has Diabetes. Sibling alive and well. 

ROS:

General: Denies fatigue, weight changes, fever, or chills.

HEENT: Positive for headache, facial pain, facial pressure, and rhinorrhea. Denies visual changes, photophobia, phonophobia, hearing loss, loss of taste, or swallowing difficulties.

Neck: No neck pain or stiffness.

Skin:  No skin color changes, itching, rashes, or lesions.

Cardiovascular:  No edema, palpitations, chest pain, or exertional dyspnea.

Respiratory: No cough, sputum production, chest pain, or shortness of breath.

Gastrointestinal:  No appetite changes, epigastric pain, abdominal pain, bowel changes, or rectal bleeding.

Genitourinary:   No penile discharge, dysuria, blood in urine, or urinary urgency/frequency.                   

Neurological:  Positive for headache. No dizziness, black spells, altered conscious levels, or tingling sensations.

Musculoskeletal:  No muscle pain, back pain, joint pain, or stiffness.

Hematologic:  No history of bleeding gums, anemia, or blood transfusion.

Lymphatic’s:  Negative for lymph node enlargement.

Psychiatric:  No anxiety or depressive symptoms.

Endocrinologic:  No heat/cold intolerance, increased urine production, acute thirst, or excessive hunger.

Allergies:  Allergic to smoke and air sprays.

Objective History

Physical Exam:

Vital Signs: BP- 118/76 mm Hg; Resp- 22; PR- 88; Temp- 98.78 F

                     Weight- 137 lbs.; Height- 5’5; BMI- 22.8

General: The client is well-groomed and appropriately dressed for the weather. He is alert and in no acute pain or distress. Oriented to person, place, and time; maintains eye contact and has clear speech.

HEENT: Head: Atraumatic and normocephalic. Hair is black, well-distributed, with no scalp tenderness. Tenderness on the cheekbones and jawline. Eyes: Sclera is white and conjunctiva pink. PERRLA with no excessive lacrimation. Tenderness on the orbital area and frontal sinus are palpable. Ears: T.M.s clear. Minimal pus present but with no ear discharge. No mastoid bone inflammation. Nose: Rhinorrhea with clear nasal discharge. Tenderness on the bridge of the nose. Throat: Mucous membranes pink and moist. Tonsillar glands are non-erythematous. 

Neck: Full ROM of the neck. The trachea is midline. The thyroid gland is normal on palpation.

Respiratory: Respirations smooth, chest rise and falls in unison on inspiration and expiration. Lungs clear on auscultation.

Cardiovascular: No edema or jugular vein distension. Capillary refill- 2 seconds. S1 and S2 are present. Gallop sounds, systolic murmurs, and frictions rub absent.

Neurological: Speech is clear with normal volume and rate. C.N.s intact. Muscle strength 5/5.

ALSO READ:

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NUR 600 Assignment 3.2: Using the Seven Attributes with a Subjective Abnormal Finding

NUR 600 Discussion 4.1: Sequence During a Physical Examination

NUR 600 Assignment 4.2: Assessment of the HEENT System Write-Up

NUR 600 Discussion 5.1: Lung Diagnoses

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NUR 600 Discussion 6.1: Cardiovascular Diagnoses

NUR 600 Assignment 6.3 Assessment of the Cardiovascular System Write-Up

NUR 600 Discussion 7.1 Common and Less-Common Diagnoses for the Breasts and Abdomen

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NUR 600 Assignment 8.2: Assessment of the Peripheral Vascular and Nervous Systems Write-Up

NUR 600 Assignment 9.1: Iatrogenic Hymenal Case Study Write-Up

NUR 600 Discussion 10.1: Musculoskeletal System Diagnoses

NUR 600 Assignment 10.2: Musculoskeletal and Neurological Write-Up

NUR 600 Discussion 11.1 Crucial Conversations

NUR 600 Assignment 11.2: Writing a SOAP Note

Assessment

Differential Diagnoses

Sinus Headache: Common symptoms of a Sinus headache include facial pain and pressure, nasal and sinus congestion, and headache. The headache is usually pulsating or throbbing and is moderate to severe. It usually occurs in the sinuses, the area of the cheeks above the maxillary sinus, the bridge of the nose above the ethmoid sinus, or the eyes above the frontal sinus (Maurya et al., 2019). Sinus Headache is a presumptive diagnosis based on DP’s symptoms of throbbing, intermittent, diffuse, moderate headaches. Besides, the headache is aggravated by activity. He also has pressure above the eyes, nose, cheekbones, and jaw, where the sinuses are located. Other pertinent positive findings include rhinorrhea, nasal drip, tenderness over sinus areas, palpable sinuses, and a history of chronic sinusitis.

Cluster Headache: It manifests with headache attacks that are usually severe or very severe and strictly unilateral pain occurring in the orbital, supraorbital, or temporal regions (De Corso et al., 2018). It lasts 15 to 180 minutes and can occur once to 8 times a day. This is a differential diagnosis based on the patient’s symptoms of headache, pain in the orbital, supraorbital, or temporal regions, and nasal congestion. However, DP has a diffuse, bilateral headache, ruling out a primary Cluster headache diagnosis.

Episodic Tension-Type Headache (TTH): Episodic TTH is a differential diagnosis based on pertinent positive findings of the diffuse headache of moderate intensity. Pertinent negative findings include a non-pulsating headache and scalp and neck tenderness (García-Azorín et al., 2020). Besides, the patient’s headache is aggravated by activity, which rules out TTH as a possible diagnosis.

Plan

Medication plan: Tylenol 500 mg PRN.

Saline nasal spray to thin mucus.

Phenylephrine nasal decongestant alleviates sinus swelling and drains mucus (Maurya et al., 2019).

Non-pharmacologic: Warm compressions on tender areas of the face.

Health Education: The patient will be educated on regular physical exercises, stretching, massage, balanced meals, and adequate sleep to prevent frequent headaches. Massage helps to relieve tight muscles in the back of the head, neck, and shoulders, alleviating headaches (May, 2018).

Consultation: Otolaryngology consultation if the headache worsens.

References

De Corso, E., Kar, M., Cantone, E., Lucidi, D., Settimi, S., Mele, D., Salvati, A., Muluk, N. B., Paludetti, G., & Cingi, C. (2018). Facial pain: sinus or not? Acta otorhinolaryngologica Italica: organo ufficiale Della Societa italiana di otorinolaringologia e chirurgia cervico-facciale, 38(6), 485–496. https://doi.org/10.14639/0392-100X-1721

García-Azorín, D., Farid-Zahran, M., Gutiérrez-Sánchez, M., González-García, M. N., Guerrero, A. L., & Porta-Etessam, J. (2020). Tension-type headache in the Emergency Department Diagnosis and misdiagnosis: The TEDDi study. Scientific reports, 10(1), 2446. https://doi.org/10.1038/s41598-020-59171-4

Maurya, A., Qureshi, S., Jadia, S., & Maurya, M. (2019). “Sinus Headache”: Diagnosis and Dilemma?? An Analytical and Prospective Study. Indian journal of otolaryngology and head and neck surgery: official publication of the Association of Otolaryngologists of India, 71(3), 367–370. https://doi.org/10.1007/s12070-019-01603-3

May A. (2018). Hints on Diagnosing and Treating Headache. Deutsches Arzteblatt international, 115(17), 299–308. https://doi.org/10.3238/arztebl.2018.0299

NUR 600 Discussion 11.1 Crucial Conversations

Crucial Conversations 

Healthcare professionals should work comfortably and in safe settings, free from disruptions. However, disruptive behaviors are widespread in clinical settings and typify workplace incivility, characterized by discourteous and rude behaviors toward colleagues (Atashzadeh Shoorideh et al., 2021). Disruptive behaviors significantly affect patient safety and should be addressed via honest conversations and sustainable approaches. Crucial conversations denote the determination to openly break the silence and address disruptive behaviors. 

Among the crucial conversations, the administration’s failure to go public about the pervasiveness of concerns is typical in healthcare settings. Here, organizational leaders overlook the severity of disruptive behaviors and overlook their impacts. As Layne et al. (2019) noted, leaders’ failure to address disruptive behaviors influences negative behaviors among nurses, leading to negative clinical outcomes. The other crucial conversation I have seen healthcare practitioners and leaders struggling with is leaders not empowering caregivers adequately to confront disruptive behaviors. In clinical practice, disruptive behaviors are diverse and frequently occur. The lack of policies and practices to encourage nurses to speak up when they encounter problems is a significant barrier to patient safety and care quality. 

Interventions to encourage crucial conversations imply a determination to prevent patient harm and unacceptable error rates associated with disruptive behaviors. An effective intervention to stop/deter disruption is adopting a zero-tolerance policy, which healthcare organizations use to prevent workplace violence (Murray, 2021). A culture change is crucial in healthcare settings to encourage reporting. Similarly, healthcare organizations should adopt a reporting culture that helps nurses to report disruptive behaviors instantly and anonymously. Leaders should also be committed to addressing disruptions immediately after they are reported and satisfactorily. Above all, nurses should be helped to identify disruptive behaviors through awareness training (Hicks & Stavropoulou, 2022). Their ability to identify disruptive behaviors, report them, and openly encounter them would be a significant step toward high patient safety and care quality. 

References 

Atashzadeh Shoorideh, F., Moosavi, S., & Balouchi, A. (2021). Incivility toward nurses: a systematic review and meta-analysis. Journal of Medical Ethics and History of Medicine, 14, 15. https://doi.org/10.18502/jmehm.v14i15.7670 

Hicks, S., & Stavropoulou, C. (2022). The effect of health care professional disruptive behavior on patient care: a systematic review. Journal of Patient Safety, 18(2), 138–143. https://doi.org/10.1097/PTS.0000000000000805 

Layne, D. M., Nemeth, L. S., Mueller, M., & Martin, M. (2019). Negative behaviors among healthcare professionals: Relationship with patient safety culture. Healthcare (Basel, Switzerland), 7(1), 23. https://doi.org/10.3390/healthcare7010023 

Murray, E. (2021). Nursing leadership and management: for patient safety and quality care. FA Davis.