GI/GI SOAP Note (Pertinent Experience)

CLASS NAME: PRACTICUM IMMERSION
LESSON: Practicum Gastroentology/Genitourinary Disorders
DISCUSSION 7.1: GI/GU SOAP Note (Pertinent Experience)
Introduction
The first lesson of Module 7 explores disorders involving gastroenterology/genitourinary disorders. You will learn the different epidemiology, pathophysiology, clinical presentation, management, and treatment of these conditions.
In this module in Board Vitals, we will be going through GI and GU disorders. You will also have a discussion of a pertinent experience that you have had during your practicum of some type of GI or GU disorder. Please make sure to use a SOAP note format and follow the rubric for this discussion.
You also have a Checkpoint for Typhon number six that needs to be completed, and you should also complete your Case Presentation Instructional Plan. This is a plan that is developed based on your case presentation that you will be doing over the next few weeks. Please make sure to follow the rubric when doing this assignment.

Learning Outcomes
At the end of this lesson, you will be able to use SOAP notes to record patient observations, assessments, and plans. (CO1, CO2, and CO8)
Note: You will find a “(CO#)” after each learning objective stated in this course to indicate which Course Outcomes are being addressed. The Course Outcomes are outlined in the Syllabus.

Learning Materials
Please have all previous textbooks for NUR 676, 677, and 678 available for your optional readings during this course. You will have optional readings throughout the course relating to your BoardVitals quizzes.
Optional Readings:
Consider reading the following in your Dains textbook:
• Chapter 3, “Abdominal Pain”
• Chapter 117, “Gastroesophageal Reflux Disease”
• Chapter 120, “Inflammatory Bowel Disease”
• Chapter 121, “Irritable Bowel Syndrome”
• Chapter 126, “Peptic Ulcer Disease”

Introduction
At the end of this assignment, you will be able to:
• Demonstrate advanced skills in physical assessment, pharmacology, and nursing interventions in the treatment of pulmonary disorders. (CO7)
• Use SOAP notes to record patient observations, assessments, and plans. (CO1, CO2, and CO8)
Discussion Guidelines
Initial Post
Respond to each of the following prompts:
1. Identify a patient with a gastroenterology/genitourinary disorder for whom you have provided care during practicum or other work experience.
2. Describe the treatment that you provided (or would provide) for the gastroenterology/genitourinary disorder and why this was chosen. Did you order any testing? Why? Any referrals?
3. Identify other differential diagnoses that may be considered for the complaint or symptom.
Initial posts should be 300–500 words. Please write following APA format and cite your references using APA style.

References that can be used:
Dains, J., Baumann, L., & Scheibel, P. (2019). Advanced health assessment & clinical diagnosis in primary care (6th ed.). Elsevier Mosby.

RUBRIC
Criteria Expectations
Content Follows directions, answers all questions thoroughly and appropriately; provides examples from personal experience where appropriate/ applicable.

Grasp of significance Projects knowledge and understanding of the significance of the assignment to professional development as an APN.
Evidence and documentation Provides thorough explanation of rationales and skillfully selects resources to substantiate conclusions.
Terminology Uses appropriate terminology correctly throughout.
Structure and mechanics Contains no spelling or grammatical errors No APA errors.

 

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