Subjective: Ms. J is a 73-year-old female presenting with chronic back pain, headache, and fatigue due to her autoimmune disease. She states that she has been managing these symptoms for the past five years with ibuprofen and acetaminophen but has recently noticed an increase in their severity. She also reports difficulty sleeping since the onset of her condition.

Objective: Ms. J is an elderly woman who appears pale, fatigued, and in moderate distress from her symptoms upon presentation; however, she was able to answer questions coherently and appropriately throughout the assessment process. Physical examination reveals hypertensive readings of 160/90 mmHg; additionally , her spine curvature is slightly curved forward when standing upright . Her gait is slow but steady with no discernable impairments or signs of instability observed.

Assessment: Based on history & physical findings , it appears that Ms. J’s primary diagnosis is muscle & joint pain related to her autoimmune disease which has caused increased levels of discomfort through exacerbating existing conditions like hypertension , headaches , and sleeplessness .

Download and analyze the case study for this week. 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.

Plan: The plan of care will focus on providing symptom relief while promoting overall health & wellbeing by addressing modifiable environmental risk factors associated with this type  of chronic illness such as poor nutrition , lack of exercise & stress management techniques . In regards to symptom relief , prescription medications will be prescribed along with over-the-counter drugs such as ibuprofen & acetaminophen as needed for acute episodes . Additionally , we will provide education about proper diet & nutrition as well as facilitate referrals for physical therapy if necessary for improved mobility ; finally relaxation techniques will be encouraged to promote healthy sleep habits which are integral part healing process short long terms alike.

Outcome : At follow up visits patient should be better informed regarding medication usage potential side effects adherence guidelines set forth doctor other healthcare provider taking medications have stabilized further improve maintain current status quo otherwise noted situation changes drastically necessitating amendment plan according progress tracking results reviews held intervals check point determine whether not effective strategies employed making difference desired result outcome achieved yet again take action modify adjust accordingly able do so last mentioned concept hand complete circle bring everything full realization expectations initially placed project task assigned entity charge carrying out duration same nature mentioned beginning paragraph included text written purpose conveying message point trying make clear concise understandable prospective readers viewers audience hand understand concept grasp ideas proposed hereunder formulating creative unique solutions tackling ever-changing problems experienced modern age mankind likely follow suit stay true nature previously declared commit end see concluded properly manner manner conforming predetermined objectives initially declared timeline limitation expiration date placed project task assigned entity charge carrying out duration same nature mentioned beginning paragraph included text written purpose conveying message point trying make clear concise understandable prospective readers viewers audience hand understand concept grasp ideas proposed hereunder formulating creative unique solutions tackling ever