Week 2: Respiratory Clinical Case APN Week 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.

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.

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.

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.

SOAP NOTE

Name:

Date:

Time:

 

Age:

Sex:

SUBJECTIVE

CC:

Reason given by the patient for seeking medical care “in quotes”

 

HPI:

Describe the course of the patient’s illness, including when it began, character of symptoms, location where the symptoms began, aggravating or alleviating factors; pertinent positives and negatives, other related diseases, past illnesses, surgeries or past diagnostic testing related to present illness.

 

Medications: (list with reason for med )

 

PMH

Allergies:

 

Medication Intolerances:

 

Chronic Illnesses/Major traumas

 

Hospitalizations/Surgeries

 

“Have you every been told that you have: Diabetes, HTN, peptic ulcer disease, asthma, lung disease, heart disease, cancer, TB, thyroid problems or kidney disease or psychiatric diagnosis.”

 

Family History

Does your mother, father or siblings have any medical or psychiatric illnesses? Anyone diagnosed with: lung disease, heart disease, htn, cancer, TB, DM, or kidney disease.

 

Social History

Education level, occupational history, current living situation/partner/marital status, substance use/abuse, ETOH, tobacco, marijuana. Safety status

 

ROS

General

Weight change, fatigue, fever, chills, night sweats, energy level

 

Cardiovascular

Chest pain, palpitations, PND, orthopnea, edema

 

Skin

Delayed healing, rashes, bruising, bleeding or skin discolorations, any changes in lesions or moles

 

Respiratory

Cough, wheezing, hemoptysis, dyspnea, pneumonia hx, TB

 

Eyes

Corrective lenses, blurring, visual changes of any kind

 

Gastrointestinal

Abdominal pain, N/V/D, constipation, hepatitis, hemorrhoids, eating disorders, ulcers, black tarry stools

 

Ears

Ear pain, hearing loss, ringing in ears, discharge

 

Genitourinary/Gynecological

Urgency, frequency burning, change in color of urine.

Contraception, sexual activity, STDS

Fe: last pap, breast, mammo, menstrual complaints, vaginal discharge, pregnancy hx

Male: prostate, PSA, urinary complaints

 

Nose/Mouth/Throat

Sinus problems, dysphagia, nose bleeds or discharge, dental disease, hoarseness, throat pain

 

Musculoskeletal

Back pain, joint swelling, stiffness or pain, fracture hx, osteoporosis

Breast

SBE, lumps, bumps or changes

Neurological

Syncope, seizures, transient paralysis, weakness, paresthesias, black out spells

Heme/Lymph/Endo

HIV status, bruising, blood transfusion hx, night sweats, swollen glands, increase thirst, increase hunger, cold or heat intolerance

Psychiatric

Depression, anxiety, sleeping difficulties, suicidal ideation/attempts, previous dx

OBJECTIVE

Weight BMI

Temp

BP

Height

Pulse

Resp

General Appearance

Healthy appearing adult female in no acute distress. Alert and oriented; answers questions appropriately. Slightly somber affect at first, then brighter later.

Skin

Skin is brown, warm, dry, clean and intact. No rashes or lesions noted.

HEENT

Head is normocephalic, atraumatic and without lesions; hair evenly distributed. Eyes: PERRLA. EOMs intact. No conjunctival or scleral injection. Ears: Canals patent. Bilateral TMs pearly grey with positive light reflex; landmarks easily visualized. Nose: Nasal mucosa pink; normal turbinates. No septal deviation. Neck: Supple. Full ROM; no cervical lymphadenopathy; no occipital nodes. No thyromegaly or nodules. Oral mucosa pink and moist. Pharynx is nonerythematous and without exudate. Teeth are in good repair.

Cardiovascular

S1, S2 with regular rate and rhythm. No extra sounds, clicks, rubs or murmurs. Capillary refill 2 seconds. Pulses 3+ throughout. No edema.

Respiratory

Symmetric chest wall. Respirations regular and easy; lungs clear to auscultation bilaterally.

Gastrointestinal

Abdomen obese; BS active in all 4 quadrants. Abdomen soft, non-tender. No hepatosplenomegaly.

Breast

Breast is free from masses or tenderness, no discharge, no dimpling, wrinkling or discoloration of the skin.

Genitourinary

Bladder is non-distended; no CVA tenderness. External genitalia reveals coarse pubic hair in normal distribution; skin color is consistent with general pigmentation. No vulvar lesions noted. Well estrogenized. A small speculum was inserted; vaginal walls are pink and well rugated; no lesions noted. Cervix is pink and nulliparous. Scant clear to cloudy drainage present. On bimanual exam, cervix is firm. No CMT. Uterus is antevert and positioned behind a slightly distended bladder; no fullness, masses, or tenderness. No adnexal masses or tenderness. Ovaries are non-palpable.

(Male: both testes palpable, no masses or lesions, no hernia, no uretheral discharge. )

(Rectal as appropriate: no evidence of hemorrhoids, fissures, bleeding or masses—Males: prostrate is smooth, non-tender and free from nodules, is of normal size, sphincter tone is firm).

Musculoskeletal

Full ROM seen in all 4 extremities as patient moved about the exam room.

Neurological

Speech clear. Good tone. Posture erect. Balance stable; gait normal.

Psychiatric

Alert and oriented. Dressed in clean slacks, shirt and coat. Maintains eye contact. Speech is soft, though clear and of normal rate and cadence; answers questions appropriately.

Lab Tests

Urinalysis – pending

Urine culture – pending

Wet prep – pending

 

Special Tests

 

Diagnosis

Differential Diagnoses

· 1-

· 2-

· 3-

Diagnosis

Plan/Therapeutics

· Plan:

· Further testing

· Medication

· Education

· Non-medication treatments

Evaluation of patient encounter

Running head: RESPIRATORY CARE PLAN 1

7

3

RESPIRATORY CARE PLAN

Respiratory Care Plan

James Bostick

South University Online

Dr. Cynthia Bostick

NSG 6001

May 6, 2020

Patient Initials JD

Subjective Data: 65-year-old female patient reports to the clinic today stating that she has been experiencing wheezing, shortness of breath, and coughing at least once daily. Patient further states that she is struggling to speak without pausing her speech to catch her breath and states affirms that she has taking her medication (albuterol) once today.

Chief Complaint: Severe wheezing, shortness of breath, and coughing at least once daily.

History of Present Illness: Patient presents repeated asthma attacks for the past 2 months (averaging more than 4 times per week). There is a record of a MVA 10 weeks ago, followed by a post traumatic seizure 2 weeks after the initial accident. Patient started on anticonvulsant drug Phenytoin. Negative seizure activity reported after commencement of drug therapy.

Medical History: History of episodic asthma attacks since the patient was in early 20s. Patient currently taking Theophylline BID and an Albuterol Inhaler PRN. Patient was diagnosed with mild congestive heart failure 3 years ago. Patient placed on sodium restrictive diet and Hydrochlorothiazide BID. Last year the patient was placed prescribed Enalapril BID due to worsening CHF. As a result, symptoms effectively controlled last year.

Surgical History: Patient denies

Allergies: NKDA

Medication List:

· Theophylline SR Capsules 300 mg PO BID for asthma

· Albuterol Inhaler, PRN for asthma

· Phenytoin SR Capsules 300 mg PO QHS for seizures

· Hydrochlorothiazide (HCTZ) 50 mg PO BID for congestive heart failure (CHF)

· Enalapril 5 mg PO BID for congestive heart failure (CHF)

Significant Family History: Patient’s father died at age 59 related to complications with kidney failure secondary to HTN. Patient’s mother died at age 62 as a result of CHF complications.

Social History: Denies being a smoker; denies alcohol. Patient admits to caffeine use: 4 cups of coffee and 4 diet colas per day.

Review of Symptoms: Patient was positive for shortness of breath, coughing, and wheezing and exercise intolerance. Patient denies headache, swelling in upper and lower extremities and/or seizures.

Objective Data:

Vital Signs: BP 171/94, HR 122, RR 31, T 96.7 F, Wt 145, Ht 5’3” BMI 26.2

*VS after Albuterol breathing treatment – BP 134/79, HR 80, RR 18

Physical Assessment Findings:

General: Well developed female appearing anxious

Integumentary: Skin pale, no bruising noted

HEENT: PERRLA, oral cavity without lesions, TM without signs of inflammation, no nystagmus noted

Cardiovascular: Regular rate and rhythm normal S1 and S2.

Respiratory: Bilateral expiratory wheezes

Gastrointestinal: Guaiac negative, abdomen soft, non-tender, non-distended with no masses

Genitourinary: Unremarkable

Musculoskeletal: +1 ankle edema on right, palpable pulses in all extremities

Neurological: A/OX3, all cranial nerves intact

Endocrine: Unremarkable

Hematologic: Unremarkable

Psychological: Patient anxious

Laboratory Test Results:

Actual Value Reference Value Conventional U.S. Unit

Na – 134 (134-142) mEq/L

K – 4.9 (3.7-5.1) mEq/L g/mL

Cl – 100 (98-108) mEq/L

BUN – 21 (6-25) mg/dL

CR – 1.2 (0.4-1.1) mg/dL

Glu – 110 (62-110) mg/dL

ALT – 24 (5-40) U/L

AST – 27 (5-40) U/L

Total Chol -190 (<265) mg/dL *women >50 yr

CBC – WNL

Theophylline – 6.2 (5-20) ug/mL

Phenytoin – 17 (10-20) ug/mL

(Fischbach & Dunning, 2017)

Diagnostic Test Results:

Chest Xray – Blunting of the right and left costophrenic angles

Peak Flow – 75/min; after Albuterol – 102/min

FEV1 – 1.8 L; FVS – 3.0 L; FEV1/FVC – 60%

Assessment:

J45.31 Mild persistent asthma with (acute) exacerbation

I50.43 Acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure

J44.9 Chronic obstructive pulmonary disease, unspecified

Plan of Care:

Diagnosis: J45.31 Mild persistent asthma with (acute) exacerbation

Education: Asthma is a chronic inflammatory disorder of that affects the lungs. Asthma causes chest tightness, coughing, wheezing and shortness of breath. Being exposed to things in the environment, like mold or dampness, some allergens such as dust mites, and secondhand tobacco smoke have all been linked to developing asthma and asthma exacerbation (CDC, 2019). Environmental and occupational factors have also been linked to asthma.

Goals: One goal for asthma management would be to prevent asthma exacerbations. Factors such as pollen and dusk can exacerbate the condition and cause further complications such as an asthma attack. Another goal for would be to limit stress. The patient came into the clinic very anxious. Stress-induced asthma can make inflammation worse, triggering breathing difficulties in the patient which could also lead to an asthma attack.

Therapeutic Management: Patients should take prescribed medications and adhere to medication regimen. Reducing stress and avoiding air pollution and allergens that may cause a flare in the condition. Patients should seek medical treatment immediately if their symptoms persist and/or get worse (CDC, 2019).

Evaluation: Individuals with asthma should monitor their breathing and follow up with their PCP to evaluate their progress. Frequency of symptoms is another key feature of the evaluation, focusing on the number of times per week the patient experience symptoms and whether they occur during the day or night (Corren, 2020).

Diagnosis: I50.43 Acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure

Education: Heart failure occurs when your heart muscle fails to pump blood as well as it should. According to the CDC (2019), it is estimated that 6.5 million adults in the United States suffer from this condition. Symptoms of CHF include, weight gain with swelling in the lower extremities, weakness, shortness of breath and difficulty breathing while lying down.

Goals: Some of the goals of treating heart failure are primarily geared toward decreasing the likelihood of exacerbation and/or disease progression. Limiting the symptoms of CHF thereby decrease the chances of mortality.

Therapeutic Management: Both early diagnosis and treatment of CHF can help improve the quality for people suffering. Treatment involves taking your medications as prescribed, reducing sodium intake, drinking less liquids, proper dieting and exercise to decrease weight, particularly in obese patients, etc.

Evaluation: People living with CHF should readily track their symptoms and discuss them with their PCP. Importance of recording fluid intake, weight and vital signs are all equally important.

Diagnosis: J44.9 Chronic obstructive pulmonary disease, unspecified

Education: Chronic obstructive pulmonary disease or “COPD,” refers to a collective of diseases that cause both breathing problems and problems with airflow blockage. Chronic bronchitis and emphysema are the two most common conditions of COPD. Similar to asthma, symptoms of this disease include dyspnea on exertion, wheezing, chest tightness, cough, etc.

Goals: The goals of effective COPD management include relief of symptoms, preventing disease progression and improving exercise tolerance to name a few.

Therapeutic Management: Management of COPD would rely on the use of bronchodilators such as Spiriva. Also, stopping smoking decreases a patient’s chances of exacerbation. Furthermore, lung therapies such as oxygen therapy and pulmonary rehab programs, could prove effective in the treatment of this disease (CDC, 2019).

Evaluation: It’s important that patients with COPD are followed by a pulmonolgist. Arterial blood gas analysis (ABG) and /or spirometry would be recommended by doctors to evaluate the function of the lungs. Patients should also monitor for an increase in symptoms that last without relief.

References

Centers for Diseases Control and Prevention (CDC). (2019). Asthma. Retrieved from https://www.cdc.gov/asthma/faqs.htm.

Centers for Disease Control and Prevention (CDC). (2019). Chronic obstructive pulmonary disease. Retrieved from https://www.cdc.gov/copd/index.html.

Corren, J. (2020). Evaluation and treatment of asthma: An overview. Retrieved from https://www.ajmc.com/journals/supplement/2005/2005-11-vol11-n14suppl/nov05-2211ps408-s415.

Fischbach, F. & Dunning, M. (2017). A manual of laboratory and diagnostic tests (10th ed.). Philadelphia, PA: F.A. Davis. ISBN: 9780803667181.

Case Study #2: Child With Spina Bifida, Myelomeningocele, Chiari II Malformation, And Hydrocephalus