D121 HEALTH PROMOTION SOAP NOTE
D121 HEALTH PROMOTION SOAP NOTE
Instructions for assignment
In order to be successful in promoting health for patients and populations across the life span, nurse practitioners need to develop and utilize key skills related to leadership, collaboration, and innovation. Additionally, these skills are utilized within a conceptual framework that helps the nurse practitioner to visualize the interconnectedness of the individual to the multifactorial influences that surround him or her.
For this task, you will develop a health promotion plan for an individual that considers how personal contacts, the environment, the greater community, and policy influence the individual’s health. The health promotion plan should be written in such a way that a diverse healthcare team comprised of interprofessional and inexperienced people can easily understand the justifications for and interventions of the plan.
You are a nurse practitioner practicing in a nurse-led primary care clinic in a rural community. You are providing care for Alfredo Garcia, a 50-year-old Hispanic male who comes to the clinic for a work physical. Alfredo does not have a regular primary care provider and has no health complaints today.
PMH: Alfredo’s past medical history includes a fractured right ankle that occurred when he was 28 years old. He has no previous surgical history or history of hospitalization.
FH: Alfredo’s father, paternal grandfather, and maternal grandmother all have diabetes. His paternal grandmother has osteoporosis and hypertension. His maternal grandfather died at 67 from colon cancer. Alfredo’s three siblings and his two children are alive and with no serious medical history.
SH: Alfredo smokes half a pack of filtered cigarettes per day, drinks two energy drinks per day, and drinks four alcoholic drinks per meal three times per week. He does not exercise regularly and eats fast food for breakfast and lunch five days a week, and dinner at home with his family. Dinner usually consists of meat (chicken, beef, or pork), tortillas, rice and beans, and one vegetable. He consumes one–two fruits or vegetables per day as part of dinner or as a snack. Alfredo is married and has two children who are in high school. Alfredo works as a construction foreman for a local construction company. He has a high school diploma.
Health promotion: He wears his seatbelt 100% of the time. Has not had a colonoscopy nor has one scheduled. Last vaccination over 10 years ago. Last dental exam two years ago.
Meds: Tylenol for back pain once per week, 1 gram per dose for two doses.
Allergies: No known drug, food, or environmental allergies.
ROS: Negative except for increased thirst and urination.
Vitals: HR: 88, BP: 155/92 R arm, seated RR: 14, WT: 245, HT: 5’8”, BMI: 37.2 kg/m2, Vision 20/35 Snellen Chart
PE: Well groomed, in no apparent distress. Head normocephalic, cranial nerves intact. Eyes PERRLA, EOMs intact. Optic disc margins sharp. TMs intact, pearly gray. Buccal mucosa pink, moist, and intact. Proper dentition. Lungs clear to auscultation bilaterally. S1S2 no murmurs. Pulses +2 throughout. No edema. Abdomen round with striae, tympanic throughout, soft, nontender. Liver span percussed at 15 cm. Uncircumcised, testis rubbery, smooth. No hernia.
No more than a combined total of 30% of the submission and no more than a 10% match to any one individual source can be directly quoted or closely paraphrased from sources, even if cited correctly. The originality report that is provided when you submit your task can be used as a guide.
You must use the rubric to direct the creation of your submission because it provides detailed criteria that will be used to evaluate your work. Each requirement below may be evaluated by more than one rubric aspect. The rubric aspect titles may contain hyperlinks to relevant portions of the course.
Tasks may not be submitted as cloud links, such as links to Google Docs, Google Slides, OneDrive, etc., unless specified in the task requirements. All other submissions must be file types that are uploaded and submitted as attachments (e.g., .docx, .pdf, .ppt).
SOAP Note with Health Promotion Focus
Analyze Alfredo’s potential health promotion activities by doing the following:
Describe sixpatient- and family-centered areas of potential health promotion for Alfredo and his family.
Explain how using motivational interviewing elicits patient-driven health promotion priorities. Include supporting scholarly literature to provide an evidence-based foundation for your explanation.
Describe fivepotential allies and five potential barriers to change for Alfredo and his family that you foresee.
Explain how incorporating the social ecological model and the readiness to change theory influences the health promotion plan, including supporting literature to provide an evidence-based foundation for your explanation.
Describe the steps that will be used to support Alfredo in developing a patient- and family-centered health promotion plan.
Describe the steps that will be used to assist Alfredo in creating SMART (specific, measurable, actionable, relevant, and timely) goals directly related to one of his priority health promotion areas.
Provide a sample SOAP note that includes eachof the following aspects:
the subjective and objective data provided
the assessment portion (diagnoses you would provide)
the plan portion with onehealth promotion item expanded to include actionable goals
Create a written follow-up plan by doing the following:
Describe the known allies and barriers to change for Alfredo and his family.
Note: Please see part A3 to choose from the 10 potential allies and barriers identified there.
Explain how involving the family and close contacts in health promotion can facilitate positive change.
Describe the steps used to support Alfredo in modifying a patient- and family-centered health promotion plan.
Analyze the progress of the plan by doing the following:
Describe the process of determining patient-centered measures of progress.
Describe the process of measuring patient-centered progress.
Describe the importance of recognizing progress that is patient-directed.
Acknowledge sources, using APA-formatted in-text citations and references, for content that is quoted, paraphrased, or summarized.
Demonstrate professional communication in the content and presentation of your submission.
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