6551 WK 3 SOAP
Gynecologic Health
Choose a affected person that you simply examined as a nurse practitioner scholar over the last three weeks of scientific on OB/GYN Situation. With this affected person in thoughts, tackle the next in a SOAP Observe 1 OR 2 PAGES :
Subjective: What particulars did the affected person present concerning her private and medical historical past?
Goal: What observations did you make in the course of the bodily Assessment?
Assessment: What had been your differential diagnoses? Present a minimal of three doable diagnoses. Listing them from highest precedence to lowest precedence. What was your major prognosis and why?
Plan: What was your plan for diagnostics and first prognosis? What was your plan for therapy and administration, together with different therapies? Embody pharmacologic and nonpharmacologic therapies, different therapies, and observe-up parameters for this affected person , in addition to a rationale for this therapy and administration plan.
Very Necessary: Reflection notes: What would you do in another way in the same affected person analysis?
Reference
Gagan, M. J. (2009). The SOAP format enhances communication. Kai Tiaki Nursing New Zealand, 15(5), 15.
Tharpe, N. L., Farley, C., & Jordan, R. G. (2013). Medical follow pointers for midwifery & Girls’s well being (4th ed.). Burlington, MA: Jones & Bartlett Publishers.
Chapter 6, “Care of the Effectively Lady Throughout the Life Span” ,“Care of the Lady Curious about Barrier Strategies of Beginning Management” (pp. 275–278)
Chapter 7, “Care of the Lady with Reproductive Health Issues”
“Care of the Lady with Dysmenorrhea” (pp. 366–368)
“Care of the Lady with Premenstrual Signs, Syndrome (PMS), or Dysphoric Dysfunction (PMDD)” (pp. 414–418)
