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Assignment: Practicum – Week 11 SOAP Note Health, Medicine Essay

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Assignment: Practicum – Week 11 SOAP Note
Select a geriatric patient that you examined during the last 3 weeks. The patient you select should be currently taking at least five prescription and/or over-the-counter drugs. With this patient in mind, address the following in a SOAP Note:
• Evaluate patient outcomes for frail elders receiving treatments for specialized areas of care*
• Evaluate the impact of environmental factors on decision making for treatment and interventions*
• Analyze strategies and resources related to supporting abused elders*
• Analyze the impact of culture on the prevalence, detection, and prevention of elder abuse*
Subjective: What was the patient’s subjective complaint? What details did the patient provide regarding his or her personal and medical history? Include a list of prescription and over-the-counter drugs the patient is currently taking. Compare this list to the Beers Criteria and consider alternative drugs if appropriate.
Objective: What observations did you make during the physical assessment? What functional assessments were used?
Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from top priority to least priority.
Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management including alternative therapies? What is your care plan for patient? How would you offer caregiver support?
Reflection notes: What would you do differently in a similar patient evaluation? How might you improve your assessment, diagnosis, and/or plan through interprofessional collaboration?
Please refer to the Learning Resources in Week 3 for guidance on writing SOAP Notes.
Resnick, B. (Ed.). (2019). Geriatric nursing review syllabus: A core curriculum in advanced practice geriatric nursing (6th ed.). New York, NY: American Geriatrics Society.

• Chapter 17, “Palliative Care” (pp. 106-116)
This chapter describes factors impacting palliative care for older adults. It then explains the role of hospice in palliative care and examines health issues that commonly impact older adults in palliative care, such as pain, loss of appetite, and loud respiration.
Holroyd-Leduc, J., & Reddy, M. (Eds.). (2012). Evidence-based geriatric medicine: A practical clinical guide. Hoboken, NJ: Blackwell Publishing.

• Chapter 14, “A Good Death: Appropriate End-of-Life Care” (pp. 175–186)
This chapter identifies aspects of a good death. It then examines pain management in older adults, including recommended treatments.
Alsop, A. (2010). Collaborative working in end-of-life care: Developing a guide for health and social care professionals. International Journal of Palliative Nursing, 16(3), 120–125.
This article examines end-of-life care concerns that must be addressed by health care providers. It also proposes strategies for addressing these concerns with patients and their families through a collaborative approach.
Ehlenbach, W. J., Barnato, A. E., Curtis, J. R., Kreuter, W., Koepsell, T., Deyo, R., & Stapleton, R. (2009). Epidemiologic study of in-hospital cardiopulmonary resuscitation in the elderly. The New England Journal of Medicine, 361(1), 22–31.
This article examines survival rates of elderly patients undergoing cardiopulmonary resuscitation (CPR) in hospital settings. It also compares the incidence of CPR among patients of different races and sexes.
McGowan, C. M. (2011). Legal Issues. Legal aspects of end-of-life care. Critical Care Nurse, 31(5), 64–69.
This article examines legal implications associated with end-of-life care. It also provides information about decision making and collaboration between patients, their families, and the medical team.
American Geriatrics Society. (2012). American Geriatrics Society updated Beers Criteria for potentially inappropriate medication use in older adults. Retrieved from http://www(dot)guideline(dot)gov/content.aspx?id=49933

This article examines three categories of medications that impact older adults: those that are potentially inappropriate and must be avoided, those that are potentially inappropriate and must be avoided in older adults with certain diseases, and those that must be used with caution.
FamilyDoctor.org. (2012). Advance directives and do not resuscitate orders. Retrieved from http://familydoctor(dot)org/familydoctor/en/healthcare-management/end-of-life-issues/advance-directives-and-do-not-resuscitate-orders.html

This website explores advanced directives, living wills, powers of attorney, and do not resuscitate orders. It also provides links to other related resources.

Essay Sample Content Preview:

Practicum-Week 11 Soap Note
Name
Institutional Affiliate
Practicum-Week 11 Soap Note
Patient Initials: J. M. Age: 78 years old Sex: Female
Subjective:
Chief Complaint (CC): “Excruciating pain on the right hip and leg after a fall in her home”
History of Present Illness (HPI): A 78 year old female admitted with a closed fracture of right femur as the primary diagnosis, undefined fracture morphology, initial encounter (HCC). Patient states that she is feeling very weak, and that she does not have any chest pains or shortness of breath.
Past Medical History (PMH): Patient’s pre-existing conditions include hypertension (HN), Diabetes Mellitus type 2 (DM2), and End Stage Renal Disease (ESRD). HN, DM2, and ESRD are chronic conditions with high prevalence among the geriatric population in the United States and around the world. The underlying chronic conditions account for the patient’s frailties as indicated by the fact that she feels very weak and thus susceptible to falls. Interventional measures to mitigate the effects of the existing chronic conditions include a wide range of medication.
Medications:
* Lisinopril 10 mg PO daily
* Atorvastatin 10 mg PO daily
* Colace 100 mg PO daily
* Metformin 500mg daily
* Tylenol 650my as needed every 4hours
The patient’s medical history further indicates that she has never undergone any major surgical procedures or surgeries in her life despite having the underlying chronic conditions.
Family History: The patient’s family background is characterized by cases of hypertension and diabetes mellitus type 2, with one of her parents succumbing to end stage renal disease as perpetuated by the two underlying conditions. The patient comes from a Hispanic family background whose medical history correlates to the patient’s underlying medical conditions as even two of her siblings out of five have been diagnosed with hypertension and diabetes mellitus type 2.
Social History: Patient is a retired community development officer with a long history of smoking stretching from her mid-20s to her late 60s. She has two daughters, and currently lives alone with occasional visits from her four grandchildren on weekends and holidays across the year. Her daughters are happily married, and with formal occupational engagements in different capacities in the private sector. Patient claims to have quit smoking for over a decade now, and has adopted a healthy dietary plan. Patient follows a strict nutritional diet of low-fat meals, and also stopped taking alcohol as well as other sugary beverages. She rarely leaves the house as most of her daily needs such as groceries are met by her children on weekends, which renders her physically inactive.
Review of Systems
Physical inactivity is a key risk factor for falls among the geriatric population in the United States and around the world. The fall may thus be as a result of the patient’s physical inactivity. The patient’s feeling of weakness and fatigue further confirms progression of the end-stage renal disease (ESRD). Absence of chest pains or discomforts indicates that there is no build up of fluids around the lining of the patient’s heart.
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