11 Jan Practice listening to the heart sounds and practice SOAP notes Discuss the difficulties encountered in assessing both young children and older adults. Remember that these age groups h
Week 2 lab activities! Complete all items listed below!
*Submit the answers in a document with references to this tab – “Week 2 lab activities” – numbered accordingly as below.
Review the announcement titled "Week 2 Additional Resources" -it contains info on videos and SOAP notes. Practice listening to the heart sounds and practice SOAP notes……
- Discuss the difficulties encountered in assessing both young children and older adults. Remember that these age groups have different emotional and cognitive developments or impairments.
- The emergency department nurse is assessing a 38-year-old man who was in a motor vehicle accident. The patient was an unrestrained driver of the vehicle. The vehicle was traveling approximately 42 miles per hour. Upon impact, the driver collided with the windshield and sustained a head injury. The patient is now stable, complaining of pain 9/10 in the head, neck, and shoulder region. Neurologic status: cranial nerves 2-12 intact; patient is awake, alert, and oriented; computed tomography scan was negative for hematoma or hemorrhage. Vital signs: T 97.5, P 68, R 16, BP 130/70. The patient is asking the nurse for pain medication; however, the nurse smells alcohol on the patient’s breath. Toxicology reports are pending.
- Based on the information presented, what subjective data will assist the nurse in making a decision to treat this patient’s pain?
- The laboratory findings showed evidence of chronic alcohol abuse. What risk factors are associated with this patient's alcohol use?
- What interventions should the nurse incorporate into the plan of care for this patient?
- Discuss “red flags” of abuse and neglect that may be found during an assessment.
- Discuss Standard Precautions and infection control methods for the protection of both the patient and the examiner.
*****See attached – Heart sounds and SOAP notes…..You can count time spent on these activities as lab hours – BE SURE TO LOG THEM!!
Your book does not have a SOAP note section, but a peer sent me one of her books that has some so I have attached the images. I have uploaded some videos/resources for SOAP notes as well. You will have a SOAP note due later in the semester, so I wanted to get you started since it is not in your reading……
SOAP notes – Remember – this is similar to an abbreviated care plan. BE CAREFUL – the medical side of healthcare does most SOAP notes, so be sure and use nursing diagnosis in the assessment, NOT medical diagnosis (unless you are referencing a prior medical diagnosis and you state this). An example of this would be:
Assessment
1) History of DMII – currently with an HGBA1C of 12 showing his/her DM is not under control.
Plan
1) Encourage the patient to monitor blood glucose levels daily and eat a proper diet. Have the patient keep a dietary log. Refer the patient to a dietician for counseling regarding a diabetic diet.
** This is when you get to show how smart you are and how great your assessment skills are…**
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