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Create a SOAP note for disease prevention, health promotion, and acute care of the patient in the clinical case. Your care plan should be based on current evidence and nursing standards of care. Visit the online library and research for current scholarly evidence (no older than 5 years) to support your nursing actions. In addition, consider visiting government sites such as the CDC, WHO, AHRQ, Healthy People 2020.

Provide a detailed scientific rationale justifying the inclusion of this evidence in your plan. Next, determine the ICD-10 classification (diagnoses). The International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-10-CM) is the official system used in the United States to classify and assign codes to health conditions and related information.

Utilize the SOAP guidelines to assist you in creating your SOAP note and building your plan of care. You are expected to develop a comprehensive SOAP note based on the given assessment, diagnosis, and advanced nursing interventions. Reflect on what you have learned about care plans through independent research and peer discussions and incorporate the knowledge that you have gained into your patient’s care plan. If the information is not in the provided scenario please consider it normal for SOAP note purposes; if it is abnormal, please utilize what you know about the disease process and write what you would expect in the subjective and objective areas of your note.

Paper For Above Instructions

The creation of a SOAP note for a clinical case involves a systematic approach that combines elements of disease prevention, health promotion, and acute care. The SOAP framework, which stands for Subjective, Objective, Assessment, and Plan, allows healthcare professionals to provide comprehensive patient care tailored to individual needs.

Subjective Section

The subjective portion of the SOAP note captures the patient's point of view regarding their health condition. For instance, consider a patient diagnosed with Type 2 Diabetes Mellitus. The patient might report symptoms such as increased thirst, frequent urination, and fatigue. Furthermore, emotional factors such as stress related to managing their condition could also be included. Engaging effectively with the patient during this section is crucial, as it helps in understanding their perspective and aids in building rapport.

Objective Section

The objective section comprises measurable data that the healthcare provider collects through physical examinations, laboratory tests, and imaging studies. For a diabetic patient, relevant vitals would include a blood glucose level, blood pressure, and body mass index (BMI). Regular blood tests might show elevated HbA1c levels, indicating poor long-term glucose control. Healthcare providers can also consider results from various assessments, such as a foot examination to check for ulcers, which is particularly important due to the complications associated with diabetes.

Assessment Section

The assessment section synthesizes the subjective and objective data to formulate a nursing diagnosis. Using the data gathered, the diagnosis could indicate that the patient's diabetes management is insufficient, leading to uncontrolled blood glucose levels. According to the American Diabetes Association (2021), patients with uncontrolled diabetes are at increased risk for complications, including cardiovascular disease, nerve damage, and kidney failure. The nursing diagnosis would include a statement about the patient's current reading and a problem statement indicating the risk of complications arising from unmanaged diabetes.

Plan Section

The plan entails designing a comprehensive care approach that incorporates evidence-based nursing interventions. According to the CDC (2021), lifestyle modifications, including nutritional counseling and physical activity, are paramount in managing Type 2 Diabetes Mellitus. The care plan could specify that the patient should aim for a carbohydrate-controlled diet, attend regular diabetes education classes, and incorporate at least 150 minutes of moderate exercise per week.

In addition to lifestyle modifications, medication management is essential. The American Association of Diabetes Educators (2020) emphasizes the importance of medication adherence, thus regularly reviewing and adjusting the prescribed medications as necessary will be part of the nursing intervention. Moreover, follow-up appointments should be scheduled to monitor progress and reassess the care plan as needed.

Scientific Rationale

This care plan reflects current evidence and standards of care as recommended by various healthcare authorities. The integration of dietary management and physical activity aligns with findings from a systematic review by Naumann et al. (2019), which indicates that lifestyle changes can significantly reduce the risk of diabetes-related complications. The importance of monitoring HbA1c levels every three months is supported by the American Diabetes Association (2021) guidelines, as they are critical in assessing long-term glucose control.

Furthermore, education on foot care is crucial for diabetic patients, as emphasized by the CDC (2021) to avoid complications such as diabetic neuropathy. Interventions focusing on foot care can prevent serious complications, including amputation.

ICD-10 Classification

The appropriate ICD-10 classification for a patient with Type 2 Diabetes Mellitus is E11, which stands for Type 2 Diabetes Mellitus. This classification aids in the organization and communication regarding the patient’s health condition across various healthcare settings.

Conclusion

In conclusion, developing a SOAP note requires integrating patient information with evidence-based interventions to create an effective care plan. The SOAP framework allows healthcare providers to structure their assessments and plans logically, ensuring that patient care is holistic and comprehensive. Following the guidelines set by respected health organizations enhances the quality of care provided, ultimately leading to better health outcomes for patients.

References

• American Association of Diabetes Educators. (2020). 7 Self-Care Behaviors. Retrieved from [Insert URL]
• American Diabetes Association. (2021). Standards of Medical Care in Diabetes—2021. Diabetes Care, 44(Supplement 1), S1-S232. doi:10.2337/dc21
• Centers for Disease Control and Prevention. (2021). National Diabetes Statistics Report. Retrieved from [Insert URL]
• Naumann, F., et al. (2019). Effect of lifestyle changes on the prevention of Type 2 diabetes: A systematic review and meta-analysis. Diabetes Care, 42(9), e95-e108. doi:10.2337/dc19-0452
• World Health Organization. (2020). Global report on diabetes. Retrieved from [Insert URL]
• Agency for Healthcare Research and Quality. (2020). Evidence-Based Practice: Diabetes Management. Retrieved from [Insert URL]
• Healthy People 2020. (2020). Diabetes. Retrieved from [Insert URL]
• American College of Cardiology. (2020). Diabetes and Cardiovascular Disease. Retrieved from [Insert URL]
• National Institute of Diabetes and Digestive and Kidney Diseases. (2021). Diabetes Overview. Retrieved from [Insert URL]
• International Classification of Diseases, Tenth Revision. (2021). ICD-10-CM Codes. Retrieved from [Insert URL]