ASSIGNMENT – SCHOLARLY PAPER
Case Scenario and Questions:
Mr. Chestnut is an 89 year old client who has just had a big gathering of family members at his bedside for a visit. The family members had just brought in drinks and snacks to celebrate Mr. Chestnut’s birthday. He is quiet and staring out the window. You have to call his name out loudly before he hears you. You take his vital signs: 38.0C, 22, 98, 138/96mmHg. He is comfortable in bed and reading his newspaper.
Based on the Case Study and assigned system given to the student, the student will create a SOAP note. A SOAP note consists of subjective data, objective data, an assessment and a plan for your client.
This portion of the SOAP note should include a statement (s), preferably in the patient’s own words regarding the chief complaint or why the patient has presented to the health care facility – i.e. why is he/she here?
The case study will provide you with some of the subjective data. When writing your SOAP note you also need to include missing subjective date in the form of questions the nurse would ask to obtain subjective data to complete the history.
This objective data should include information obtained via the physical exam, laboratory analysis, x-rays, etc.
Your objective data will come from the physical examinations that you feel are necessary based on the case study. Doing unnecessary exams on the patient will result in lost marks. This data needs to be referenced.
Assessment is the nursing diagnosis portion of the SOAP note. Nursing diagnosis are actual or potential problems this patient may have.
The student needs to prioritize the problems related to the Case Study and associated system assigned.
Through readings and further research, the student will provide their rationale for each of the problems identified.
Through readings and further research, the student will provide a plan.
The plan will include three nursing interventions along with their rationale (referenced). Each nursing intervention will be based on the problems identified in the assessment portion of the assignment.
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