D121 Task 1 Creation of a Health Promotion SOAP Note

D121 Task 1 Soap Note

SOAP Note

Student name

Western Governors University

D121

Professor name

Submission date

Creation of a Health Promotion SOAP Note

Alfredo Garcia is a 58-year-old Hispanic male who has several other risk factors (modifiable) that influence his health (obesity, hypertension, smoking, and excessive alcohol consumption). He also has an extensive family history of diabetes and hypertension; however, his lifestyle choices will put him at higher risk for chronic diseases. Three patient/family-centered approaches and a strong focus on changing three health behaviors – quitting smoking, changing diet, and increasing physical activity – must be incorporated into the health promotion plan that is designed for Alfredo. This plan incorporates motivational interviewing skills, determining potential allies and barriers, and considering using the Social Ecological Model and Readiness to Change Theory to change behavior.

Six Patient- and Family-Centered Areas of Potential Health Promotion

Smoking Cessation: Alfredo is a tobacco user, which increases his risk for cardiovascular disease, as well as cancer. Stopping smoking could benefit not only his health, but also help to reduce the effects of secondhand smoke for those around him.
Dietary Improvement: Alfredo has become obese, eating too much fast food with starchy foods such as rice, tortillas, and beans, predominantly in his diet. The foods his family prepares are high in carbs and very little healthy food, like veggies and chicken. Now, if Alfredo can eat healthier and eat veggies and protein, his family will be able to help him eat healthier, too.
Increased Physical Activity: Alfredo is not exercising regularly, which could be a factor in his obesity and hypertension. The family might have more opportunities to exercise together on a regular basis, for both Alfredo and the family.
Alcohol Reduction: He often stops drinking at around two o’clock after dinner, which is a problem because he usually consumes approximately four alcoholic beverages at dinner a couple of times a week. His liver and cardiovascular system will be negatively impacted if he doesn’t reduce the amount of alcoholic beverages he consumes; he must work to reduce his alcohol consumption (alcohol) now. If he were to restrict alcohol use at home (either by not allowing him access), then his family can assist him in locating social activities that do not involve alcohol use.
Preventive Health Screenings: Alfredo’s family can schedule their own proactive/preventive health screening, which will help to create a culture of health awareness for the family. Colonoscopy, vaccinations, and routine health check-ups will not be scheduled if they are delayed for more than 10 years, as Alfredo did.
Chronic Disease Education: It’s important to provide education on ways to prevent and manage chronic disease to both Alfredo and his family because they will be able to help instil healthy behaviours into their children when they’re young, especially since both diabetes and hypertension run in Alfredo’s family history.

Motivational Interviewing and Patient-Driven Health Promotion

The aim of this course is to examine motivational interviewing and patient-driven health promotion.

Client-centered health goals for Alfredo include motivating him to set health goals with MI, asking him questions to explore the shifting rationale, including a cognitive component to address ambivalence. To get him to really come to the table, the nurse practitioner might say, for example, “Well, what are your health concerns about your health?” This question will give him a chance to talk to his partner about these issues, too, regarding his weight and smoking. MI is intended to help motivate Alfredo to engage in self-directed behaviour change (Zhu, 2022). The more the health professional emphasizes reflective listening and affirmations of changes in the direction of providing a supportive environment, the longer amount of time that it may take for him to continue to look for ways to change his diet and quit smoking. For instance, the provider might tell Alfredo, “You will want to be with your own family as long as you can be. What would you have to do to achieve that goal if you quit smoking?” MI demonstrates that if patients have the ability to create their own health goals, they will increase their chances of successfully stopping smoking and developing positive behavioural changes in their lifestyles (Melnick et al., 2021).

Five Potential Allies and Barriers to Change

Allies

Family: His wife and children can assist him in changing his eating habits, engaging in increased exercise, and reducing smoking and alcohol.
Workplace Wellness Programs: Alfredo is a construction foreman who might be able to participate in workplace wellness programs, including smoking cessation, health screening, and/or fitness incentives.
Local Healthcare Services: Rural clinics and community health centers can serve as a source of continual preventive care and assistance for Alfredo’s health promotion objectives, like smoking cessation or weight loss counseling.
Community Resources: Alfredo and his family may participate in local physical activity programmes, community-based walking groups, etc., to reduce barriers to physical activity.
Peer Support Groups: Alfredo may find support in a quit smoking program or group, or in a program to help him with alcohol.

Barriers

Cultural Food Habits: Alfredo may feel a struggle with making dietary changes because the change will require him to reduce his consumption of traditional foods that are high in carbohydrates and fats, including tortillas, rice, and beans, which may be his favorite family foods.
Time Constraints: Alfredo’s full schedule as Foreman may be making it harder for him to find time to exercise or to go visit his physician for routine health care.
Access to Healthcare: It can be hard for Alfredo to keep his appointments or to get preventive services if he lives in a rural area where healthcare may not be as readily available.
Resistance to Change: Alfredo may resist change; he may be tied to some older ways of doing things, like smoking, following a special diet, or other routines, which may have been established over years of habit.
Financial Concerns: The most effective healthiest foods or fitness programs may come with a high price tag, which will prevent Alderhito and his family from enjoying health and wellness.

Incorporating the Social Ecological Model and Readiness to Change Theory

The Social-Ecological Model (SEM) is a model of how the environment within which people live shapes health behaviours such as smoking and unhealthy eating. Alfredo’s health behaviours are not necessarily the ones that Alfredo decides to undertake, but rather the health behaviours of his closest friends, family, and social networks, and how his social environment in his home community and/or workplace affects his health behaviours. Health behaviours are influenced by multiple different levels – individual, interpersonal networks, health-care systems, and government policies – and therefore, when developing intervention strategies, they should include the use of a variety of different intervention strategies across these different levels, in order to create the greatest likelihood of creating long-term behaviour change (Colizzi et al. 2020).

For instance, by planning groceries and preparing meals at home, Alfredo’s family can make some changes that may impact the food available to Alfredo. The Workplace Wellness Program could also incorporate the use of various programs that could be used in accordance with meeting Alfredo’s health care needs. For assessment purposes, it is likely that the best assessment tool will be the Transtheoretical Model (Stages of Change) (Jiménez-Zazo et al., 2020) in order to determine where Alfredo is in the change process regarding his diet. Alfredo probably is in the precontemplation phase of change, and may be at the individual stage of the TTM as a result of social factors influencing him in his food choices.

Supporting Alfredo in Developing a Health Promotion Plan

Initial Discussion and Goal Setting: Identify, using MI techniques, Alfredo’s motivations for change, such as his wish to improve his health for his children’s sake.
Education and Resources: Give Alfredo and his family cigarette quitting information, healthy eating, and physical activity.
Collaborative Goal Setting: Create realistic, specific goals with Alfredo and his family to decrease smoking and increase diet changes.
Resources: Link Alfredo to local smoking quitting programs and fitness programs. Give details regarding rural health services that may help to support routine health screening and checkups.
Follow-up and Adjustments: There will be follow-up visits and adjustments to the health promotion plan as required.

SMART Goals

The first step in helping Alfredo to quit smoking is to assess his readiness to quit. Based on the “Readiness to Change” model, an evaluation will determine what type of motivation he has to quit smoking and how ready he is to begin reducing or giving up smoking completely. We will be able to help him communicate his concerns, priorities, issues with stopping smoking, and what he needs to help him quit via motivational interviewing techniques and recognition that quitting is an individual and progressive process.

Once he is willing to change, the second phase of working with Alfredo on smoking cessation will be coming up with a concrete plan or goal for him. For instance, if he wants to cut back on the amount of cigarettes he uses each day, but has not decided how much, this may be a clear and reasonable goal: to go down from 10 cigarettes a day to 5 cigarettes a day. Once there is a clearly defined goal, it can also be quantified (i.e., how many times throughout the week does he smoke; how many times per day does he smoke). It is suggested that Alfredo maintain a smoking journal that will show how many cigars he lights a day and that he decrease the number of cigars he smokes.

SOAP Note

Alfredo stated that he was thirsty and was going to the bathroom a lot, but that he didn’t have any other significant symptoms. He is worried about his weight and hypertension, but has trouble exercising on a regular basis, he said. When he went in for his examination, his blood pressure was 155/92 mmHg, heart rate was 84 beats per minute, BMI was 37.2 kg/m2, and vision was 20/35. The read-out for the FBG was 125 mg/dl, a pre-diabetic indication. HbA1c was 6%, electrolyte levels were normal, and serum creatinine and BUN 1 mg/dL and BUN 14 mg/dL were within normal limits, indicative of normal renal function.

Their lipid profile revealed high LDL (140mg/dl), total cholesterol (210mg/dl), and triglycerides (190mg/dl), which resulted in a high risk of cardiovascular diseases. Urine microscopy showed a trace amount of glucose and negative protein, ketones, leukocytes, and nitrite. TSH was normal (2.5 microliter/mL), and the microalbumin to creatinine ratio was elevated (35 mg/g). Within a week of that, laboratory tests of both the blood and the urine were ordered, with the results to be reviewed two weeks later.

Physical exam was focused, and the patient was alert and oriented, and slightly overweight. HEENT examination was normal with equal, round, and reactive pupils, no conjunctival pallor or icterus, and a clear oropharynx. Cardiovascular examination was normal for rate and rhythm, and no murmurs or edema were found. Lung auscultation was normal without any crackles or wheezes on either side. There was no hepatosplenomegaly, and the abdomen was soft and non-tender. On musculoskeletal examination, the range of motion was normal with no deformities or swelling, and neurological examination revealed the integrity of all the cranial nerves with no focal neurologic deficit. The assessment findings included evidence of obesity, hypertension, pre-diabetes, and tobacco use disorder.

This treatment plan included a referral and initiating smoking cessation therapy with a 21 mg patch, slowly decreasing the nicotine content of the patch, and tapering down nicotine for six weeks. Lisinopril 10 mg per day by mouth was prescribed for blood pressure and for kidney protection, and it was asked that the blood pressure be monitored and recorded at home daily. For those who did not have any lab confirmation of pre-diabetes, 500 mg of metformin was to be initiated once daily with meals as needed and subject to future lab confirmation. Dietary counseling and family education on making healthier food choices were recommended, as was progressive introduction of more walking, which was encouraged to be done 15 minutes at a time, three times a week, with the support of the family.

Alfredo’s prescription was to drink one or two alcoholic beverages weekly, if necessary, but to drink water and non-alcoholic drinks whenever possible. Influenza vaccine was administered at the time of the visit, colonoscopy was scheduled within one month, and vision exam was scheduled within one month; Tdap vaccination was provided if more than 10 years had passed since the last dose was actually administered (preventative care recommendations made). The patient was seen for follow-up one month later; the treatment plan was to be revised.

A health promotion plan regarding smoking cessation will be done to deal with Alfredo’s smoking. This plan will include a SMART plan for Alfredo: In one month, he will decrease his half pack (or more) per day cigarette usage to 5 cigarettes per day. To achieve this, we will use motivational interviewing at follow-up appointments to elicit his motivation for quitting and discuss challenges. Alfredo will be asked to maintain a smoking diary every day, which will include how many cigarettes he smoked, when, and what made him feel anxious about smoking, what he craved to smoke, and any other trigger for using cigarettes.

We will also be giving out literature about smoking and how it can harm his health and cause hypertension! Pharmacological support, such as nicotine replacement therapy or prescription medication, will be discussed to increase his chances of success, as well as local support, such as smoking cessation programs (Hersi et al., 2024). Alfredo will be visiting us regularly, every 2 weeks, to see how he is doing, to provide encouragement, and if necessary, make revisions to the plan based on Alfredo’s input. It aims to offer a setting which enables him to alter his own habits positively and to improve his health results generally.

Follow-Up Plan for Alfredo

Allies and Barriers to Change

Alfredo Garcia and his family have a number of known facilitators and inhibitors on their path to positive health. Family members, particularly his wife and children, can also be great sources of encouragement and assistance in improving the family atmosphere. Social support includes colleagues in the construction industry who are also involved in health promotion activities, encouraging Alfredo to be more aware of and mindful of his health. Community resources like a local health program, smoking cessation support, or other kinds of support are ways in which information and assistance are offered to Alfredo to change (Zhu, 2022).

Unfortunately, there are also many obstacles that Alfredo has to face, such as the long timeframe of quitting smoking and the high degree of addiction related to forming a nicotine-dependent person (Thomson et al., 2019). On a construction site, either through social norms or beliefs, the work environment can lead to the devaluation or valorization of health. Furthermore, Alfredo’s work and/or family responsibilities will also bring stress to his life, so he will have limited capacity to engage in activities that will improve his health or help to provide him with a lifestyle conducive to making healthy decisions.

Involving Family and Close Contacts in Health Promotion

Alfredo needs to include his close family and contacts in his health promotion activities. Families have a decisive effect on the way in which they get used to health behaviors and attitudes. If he does become a part of these conversations, then he can bring his family along too, and they can establish a healthy environment where he is able to make healthy choices. For example, using family meal planning to begin a healthy eating program and family activities to increase physical activity. Furthermore, family members, knowing the goal of what is to be accomplished with Alfredo, will be able to help hold him accountable, keep him motivated, and help celebrate his steps ever so often. This shared participation enables them to feel a sense of responsibility and promotes greater ownership of health promotion endeavours and willingness to change lifestyle behaviours.

Modification of Health Promotion Plan

Alfredo will have a collaborative approach to change his health habits, with input from her in discussing what each person’s idea and feelings are about the specific #health change, so that everyone is heard. These ideas will be incorporated into the Health Promotion Plan so that Alfredo can make it a part of his everyday lifestyle. A family meeting will be held regularly to review how well, as a family, they are doing in changing the health habits of Alfredo, and to talk about the difficulties that will occur. This will enable all family members to be able to support each other while encouraging Alfredo to make healthier food choices. Educational resources that will be useful to the whole family will be shared, including information on the benefits of healthy eating and how healthy eating options will benefit all. During this process, the health promotion strategies will constantly be tweaked to accommodate feedback from Alfredo and his family to keep the health promotion strategies relevant and possible for Alfredo.

Analysis of Progress of the Plan

Determining Patient-Centered Measures of Progress

Alfredo’s health-related goals and specific indicators will be identified to measure patient-centered progress toward his health goals. Taking note of his cigarette consumption over time, blood pressure, weight, and diet will be part of these measures (Odorico et al., 2019). Regular follow-up appointments will also discuss his feelings and challenges around health changes and provide not only numbers, but qualitative measures of progress as well.

Measuring Patient-Centered Progress

Alfredo will be assessed qualitatively and quantitatively. The quantitative pounds/blood pressure will be taken at each follow-up visit to document physical changes related to his health promotion efforts. The time charted will be the frequency of smoking as well as the frequency of his stopping smoking, so he’ll smoke less. Qualitative conversations will take place during appointments and will qualitatively inquire into his perception of the changes, barriers he is encountering, and how family involvement is impacting his journey. By taking this dual approach, the progress of Alfredo can be evaluated from a clinical and personal side, which together help to develop a holistic awareness of Alfredo’s well-being.

Recognizing Patient-Directed Progress

It is important to acknowledge progress that is directed by the patient to support motivating them to maintain positive changes in behaviour. Regardless of the size of his actual success he may have, such as Alfredo’s, recognizing it helps him reaffirm his confidence and commitment in the health promotion plan. Achievements such as reaching his own target on cigarettes, which he has recently quit, or exercising regularly can help to reinforce his efforts. Also, awareness that the change may not always be linear in nature is a measure of resilience and adaptability: Alfredo shall feel more empowered to take charge of the progress, and, probably, would be listening to patient-driven change, leading to lifestyle changes that are more likely to be lasting and improve health outcomes.

References

Hersi, M., Beck, A., Hamel, C., Esmaeilisaraji, L., Pussegoda, K., Austin, B., Ahmadzai, N., Pratt, M., Thuku, M., Yazdi, F., Bennett, A., Shaver, N., Vyas, N., Skidmore, B., Hutton, B., Manuel, D., Morrow, M., Pakhale, S., Presseau, J., & Shea, B. J. (2024). Systematic Reviews, 13(1), 179. https://doi.org/10.1186/s13643-024-02570-9

Melnick, R., Mendonça, C. S., Meyer, E., & Faustino-Silva, D. D. (2021). Effectiveness of motivational interviewing in smoking groups in primary healthcare: a community-based randomized cluster trial. Cadernos de Saúde Pública, 37(3). https://doi.org/10.1590/0102-311×00038820

Odorico, M., Le Goff, D., Aerts, N., Bastiaens, H., & Le Reste, J. Y. (2019). Vascular Health and Risk Management, 15, 485–502. https://doi.org/10.2147/VHRM.S221744

Persell, S. D., Peprah, Y. A., Lipiszko, D., Lee, J. Y., Li, J. J., Ciolino, J. D., Karmali, K. N., & Sato, H. (2020). Effect of home blood pressure monitoring via a smartphone hypertension coaching application or tracking application on adults with uncontrolled hypertension: A randomized clinical trial. JAMA Network Open, 3(3), e200255–e200255. https://doi.org/10.1001/jamanetworkopen.2020.0255