SOAP Note Assignment Paper

SOAP Note Assignment Paper

SOAP Note Assignment

Click here to 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. SOAP Note Assignment Paper

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. SOAP Note Assignment Paper

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Click here to access the codes.

Download the SOAP template to help you design a holistic patient care plan. 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. SOAP Note Assignment Paper

Format

• Your care plan should be formatted as a Microsoft Word document. Follow the current APA edition style. Your paper should be no longer than 3-4 pages excluding the title and the references and in 12pt font.
• Name your document: SU_NSG6001_W2A2_LastName_FirstInitial.doc.
• Submit your document to the Submissions Area by the due date assigned.Patient Initials: CF         Gender: Female                         Age: 65

  Subjective Data

  Chief Complaint

  Patient comes to the clinic with the chief complaints of shortness of breath, wheezing and mild coughing.

  HPI

  For the last 2 months, patient has experienced asthma attacks on average more than 4 times a week, posttraumatic seizure 2 weeks after the accident and serious MVA 10 weeks ago. Anticonvulsant phenytoin started recently and there has not been any seizure activity since the initiation of therapy.

  PMH

  Patient has a history of periodic asthma attacks dating back to her early 20s. Three years ago, patient was diagnosed with mild congestive heart failure and placed on hydrochlorothiazide and sodium restrictive diet. Last year, CF placed on enalapril because of worsening CHF. Medication has controlled the symptoms relatively well the last year. Apart from enalapril, other medications prescribed for the patient include albuterol inhaler, theophylline SR capsules 300 mg PO BID, and PRN Phenytoin SR capsules 300 mg PO QHS. She has no known allergies. Patient has not had any surgeries. SOAP Note Assignment Paper

  Family History

  The patient’s parents are both deceased. Her father succumbed to kidney failure at age 59 while her mother died of CHF aged 62

  Social History

  Patient attests that she is a nonsmoker and she does not consume alcohol. She takes four cups of diet colas and the same number of coffee cups SOAP Note Assignment Paper

  ROS

  Positive for cough, wheezing, exercise intolerance and shortness of breath. Denies seizures, headaches and swelling of extremities

  Gen

  Pale, well-developed Caucasian female appearing to be anxious. HEENT: PERRLA, oral cavity without lesions, TM without signs of inflammation, no nystagmus noted. Abdomen: non-tender, soft, non-distended no masses. Chest: Bilateral expiratory wheezes. Cardio: Regular rate and rhythm normal S1 and S2. Rectal: Guaiac negative. GU: Unremarkable. NEURO: A&O X3, cranial nerves intact. EXT: +1 ankle edema, on right, no bruising, normal pulses.

  Objective Data

  Vital Signs: BP 171/94, HR 122, RR 31, T 96.7 F, Wt 145, Ht 5’ 3”. After the albuterol treatment, vital signs are BP 134/79, HR 80, and RR 18

  Physical Assessment and Diagnostic Testing: Na – 134, K – 4.9, Cl – 100 (all within normal limits), BUN – 21, Cr – 1.2, Glu – 110, Theophylline – 6.2, Phenytoin – 17, ALT – 24, AST – 27, Total Chol – 190 (substantially high, predicted moderate restriction). CBC – WNL, Chest Xray – Blunting of the left and right costophrenic angles, Peak Flow – 75/min (relatively low, normal should be between 80-100/min); after albuterol – 102/min, FEV1 – 1.8 L; FVC 3.0 L, FEV1/FVC 60% (predicted moderate obstruction).

  Assessment

  1. Chronic obstructive asthma 9 (CMS.gov, 2016). Presenting symptoms that match this diagnosis include wheezing, cough, dyspnea/shortness of breath, cough and +1 ankle edema. Previous asthma attacks also place the patient at increased risk of contracting chronic obstructive asthma SOAP Note Assignment Paper
  2. Emphysema, unspecified9 (CMS.gov, 2016), as evidenced by the patient’s shortness of breath, cough, low FEV1/FVC 60%
  3. Bronchitis not specified as acute or chronic. J40 (CMS.gov, 2016) as indicated by the occasional cough, shortness of breath and bilateral expiratory wheezes SOAP Note Assignment Paper

  Care Plan

  A comprehensive care plan targeting the identified diagnoses will help in improving patient care outcomes for the 65-year-old Caucasian female. Patient must receive appropriate instruction pertaining to the possible diagnoses identified. Asthma can be a life threatening condition that causes inflammation and swelling of the airways, making it difficult to breathe. Environmental and genetic factors may play a role in asthma attacks. Bellia & Incalzi (2012) contend that other risks such as air pollution, stress and allergies can trigger asthma attacks. Emphysema on the contrary is a lung disease characterized by reduced airflow and inflammation in the lungs.  The reduced airflow results in gradual destruction of the small sacs in the lungs, subsequently manifesting symptoms such as shortness of breath, chest tightness, fatigue, a chronic cough and wheezing. Major risk factors for developing emphysema include smoking, exposure to air pollution and alpha-1-antitrypsin (ATT) deficiency (Buttaro, Trybulski, Bailey, & Sandberg-Cook, 2013). Bronchitis is also a serious lung disease that occurs due to bronchial tubes’ inflammation. The most common cause of the condition is cold virus, but bacteria can also be the cause in some cases.

  The treatment plan prioritizes medications as well as other non-pharmacological interventions. Anticipated outcomes include patient demonstrating improved oxygenation and ventilation, exhibiting effective breathing patterns, maintaining respiratory rate within normal limits and increased control of inflammatory episodes. According to Buttaro et al. (2013), the first line medication for asthma is albuterol, inhaled 1 to 2 puffs every 4 to 6 hours when the patient has breathing complications. Similarly, for emphysema, the primary medication used for reducing dyspnea and improving exercise tolerance is albuterol. Dosage approved by the FDA is 400 µg inhaled twice daily (Bellia & Incalzi, 2012). Other medications to prescribe to the patient will include metaproterenol and levalbuterol (0.2 to 0.3 mL of 5% solution). The medications target various reversible airflow limitations including bronchial smooth muscle contraction, increased airway secretions, bronchial mucosal congestion and airway inflammation. Various medications are also effective for treating bronchitis. Apart from albuterol, the other effective drug for managing the condition is amoxicillin 80 to 90 mg per kg per day taken orally. SOAP Note Assignment Paper

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  Complementary and alternative medicines will also be part of the care plan. Various studies have indicated the efficacy of some herbal remedies in the management of pulmonary conditions such as asthma, bronchitis and emphysema.  For example, in a study conducted by Akinci, Zengin, Yildiz, Sener, & Gunaydin (2011), the researchers found out that the most common and effective CAM methods utilized by the participants included deep inhalation, applying vapor, praying and herb or herbal tea. Generally, the patients in this study used CAM to relax, reduce dyspnea, breath comfortably and improve respiration. The researchers also established that these CAM methods had little to no negative side effects (Akinci et al., 2011). Because of the efficacy and safety of the herbal remedies, practitioner will consult with patient to ascertain whether she could implement any of the methods in combination with the medications prescribed. Consulting with the patient also aids practitioner to provide culturally congruent care.

  Patient will also receive education on self-care practices that can aid to improve her condition. As the European Respiratory Society (2013) points out, self-care should entail avoiding secondhand smoke, avoiding smoke from fireplaces and avoiding exposure to very cold air. It is also paramount to instruct the patient about the proper use of cough suppressants, OTC fever reducers and pain relievers. Practitioner will further enlighten the patient about the importance of using forward-leaning postures in addition to learning controlled breathing techniques such as purse-lip breathing and abdominal muscle breathing (diaphragmatic breathing). Practitioner will also evaluate the patient’s knowledge pertaining to the use, care and cleansing of nebulizer and inhaler use. According to Bellia & Incalzi (2012), contaminated DPIs, MDIs, diskus, turbuhaler and nebulizer equipment are typical causes of infections. SOAP Note Assignment Paper

  Apart from the practitioner, other helping professionals will also provide care to the patient. For example, human service professionals will help patient in looking for possible assistance/community resources while spiritual leaders will offer nourishment to ensure that the patient receives holistic care. Referring the patient to psychiatric specialists is another component of the care plan that will help ease her anxiety and mild stress. Involving CF’s family members is also critical. Buttaro et al. (2013) acknowledge that warmth and cohesiveness in the family environment improves resiliency and provides a coping mechanism for the patient.

  Follow-Up Plan

  Follow-up will entail appropriate monitoring of patient’s vital signs following discharge. First follow up scheduled after 4 weeks. During the session, practitioner will conduct comprehensive physical examinations and diagnostic tests including spirometry, methacholine challenge test and chest x-rays to check the prognosis of disease (European Respiratory Society, 2013). Patient to share information about any side effects or allergies associated with the medications she is taking. Appropriate measures will be taken to ensure adherence, compliance and improved outcomes.

  References

  Akinci , A., Zengin , N., Yildiz , H., Sener , E., & Gunaydin , B. (2011). The complementary and alternative medicine use among asthma and chronic obstructive pulmonary disease patients in the southern region of Turkey. International Journal of Nursing Practiceq, 17(6), 571-582.

  Bellia, V., & Incalzi, R. (2012). Respiratory diseases in the elderly (3 ed.). Sheffield: European Respiratory Society Journals.

  Buttaro, T., Trybulski, J., Bailey, P., & Sandberg-Cook, J. (2013). Primary care : a collaborative practice (4 ed.). St. Louis, Mo.: Elsevier/Mosby.

  CMS.gov. (2016). ICD-10. Retrieved from https://www.cms.gov/medicare/coding/icd10/index.html

  European Respiratory Society. (2013). Respiratory diseases in the world: Realities of today – opportunities for tomorrow. Retrieved February 12, 2017, from https://www.ersnet.org/pdf/publications/firs-world-report.pdf SOAP Note Assignment Paper