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NU611 Clinical Decision Making
Unit 7 Discussion
Evidence-Based Practice
Instructions:
Review the partial SOAP note accessed through this link.
EBP SOAP NotePreview the document
Initial Post
Post a discussion constructed as the ‘P’ (treatment plan) that completes the partial SOAP note accessed through the link above.
Include in the discussion:
Your treatment plan for the first two diagnoses – structure your Plan using the format outlined in your Typhon documentation policy (e.g. diagnostics, therapeutics, educational, consultation/collaboration) Citations for each of the evidence-based practice (EBP) interventions included in your Plan For each article you cited in support of an element of the Plan provide your thoughts about the strength of the evidence presented in the article(s) Please be sure to validate your opinions and ideas with citations and references in APA format where appropriate.
The post and responses are valued at 20 points. Please review post and response expectations. Please review the rubric to ensure that your response meets criteria.
Estimated time to complete: 2 hours
Peer Response: Unit 7, Due Sunday by 11:59 pm CT
Evidence-Based Practice
Instructions:
Construct a response to at least 2 of your peers commenting – ideally one who utilized the same EBP interventions that you did and one who did not.
Please be sure to validate your opinions and ideas with citations and references in APA format where appropriate.
Subjective
CC:
“I’m having trouble sleeping, I need something to help me sleep”.
HPI:
Onset- It has been going on for years but lately it’s getting worse
Duration- I can only sleep 2 to 3 hours a night and it’s affecting my work
Characteristics – My mind races, I can’t stop thinking and even when I fall asleep, I can’t stay
asleep, I keep waking up every hour.
Associated/Aggravating- “I’m not sure”.
Relieving- “I drink beer to help me get tired and fall asleep. But I still wake up in the middle of
the night”
Treatment- “I drink beer so that I can get tired”.
Summary- 42-year-old male complaining of Insomnia for years but worse the past few years,
the patient has not tried anything over the counter but drinks 2-3 beers a night to fall asleep.
However, patient reports waking up several times a night and waking up fatigued in the morning.
The patient reports the lack of sleep is affecting his work and family life.
PMH:
Obesity-2000
Hypertension- 2011
Hyperlipidemia-2011
Allergies: NKDA
Medications:
Amlodipine 10mg daily
Atorvastatin 40mg daily
Social history:
Educational level/literacy- College.
Smoking – Denies use of tobacco or cigarettes.
Alcohol- Drinks 2-3 beers a day.
Drugs- Denies illicit drug use
Sexual Health-Currently sexually active with female spouse.
Cultural and spiritual beliefs that impact health and illness- Patient denies.
Financial resources – Patient is gainfully employed and denies financial need.
Family history:
Father: Deceased (2000)- Heart attack
Mother: Alive and Well-Hypertension, Diabetes, Depression.
Maternal Grandmother: Deceased age 75- Cancer.
Maternal Grandfather: Deceased age 90- Natural causes.
Paternal Grandmother: Deceased age 80’s- Stroke.
Paternal Grandfather: Deceased Age 65- Heart attack.
Health Maintenance/Promotion:
Immunizations:
Up to date
Screening:
Nutritional counselling – Due
Review of Systems (ROS)
General: Reports fatigue, denies pain.
Skin: Denies itching or lesions.
HEENT: Reports ability to see well without glasses. Denies hearing difficulties.
CV: Denies chest pain or discomfort.
Lungs: Denies cough or shortness of breath.
GI: Reports good appetite. Regular bowel movement, daily. Denies nausea or vomiting.
GU: Denies pain with urination, denies frequency or urgency.
PV: Denies calf pain or swelling.
MSK: Reports ability to walk with no assistive devices.
Neuro: Reports occasional headaches. Denies forgetfulness or dizziness.
Endocrine: Reports fatigue. Denies extreme thirst.
Psych: Reports frequent feelings of anxiety. Denies thoughts of suicide or self-harm.
Objective:
Physical Examination (PE):
Vital Signs: Blood Pressure 138/82, Pulse- 89, Respirations- 18, Temperature- 97.8(Oral),
Oxygen Saturation-96% room air. Height 175.2cm, weight 280lbs, BMI- 41.34
General: Appears well groomed.
Skin: Warm, dry and intact.
HEENT: Eye lids in normal position. PERRLA. Extraocular movements smooth and symmetric.
Ears equal in size bilaterally. No discharge. Lips pink and moist, no lesions.
Neck: Symmetric with no noted masses. Full range of motion. No jugular vein distention.
CV: Heart beat regular, Apical rate is 84 beats per minute, S1, S2, S3 sounds auscultated.
Lungs: Respirations even and unlabored. No pain or tenderness on palpation. Tactile fremitus
symmetric, diminished breath sounds to posterior lower lobe bases bilaterally. Non-productive
cough.
GI: Abdomen round and soft. No tenderness. Active bowel sounds x 4 quadrants. Umbilicus midline. Abdominal striae noted.
PV: No edema. No clubbing of fingertips. Bilateral extremities warm to touch. Strong pedal and popliteal pulses.
MSK: Normal flexion and extension. Able to overcome gravity. Normal spine curvature.
Neuro: Alert and oriented. No tremors or unilateral weakness. Sensation intact bilaterally. No Babinski reflexes intact at 2+.
Diagnostic Tests: Complete blood count with differential, Complete Metabolic Panel, Thyroid
panel.
Assessment:
Diagnosis/Diagnoses:
1. Insomnia
2. Obesity
3. Hypertension – Stable with current medication.
4. Hyperlipidemia – Stable with current medication.

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