SOAP Note AssignmentClick 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. Yo

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SOAP Note AssignmentClick 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 Areaby the due date assigned.

SOAP Note AssignmentClick 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. Yo
RESPIRATORY CLINICAL CASE 11 Respiratory Clinical Case study and care Plan Creation Name South University March 21, 2017. Respiratory Clinical Case Analysis Patient Initials: P.E Age: 65 Sex: Female. Subjective Data: The patient P.E complaints that she had shortage of breath, she is having severe wheezing, shortness of breath and coughing at least once daily. She can barely get her words out without taking breaks to catch her breath and states she has taken albuterol once today. Client Complaints: Shortage of breath, and coughing. HPI: P.E has frequent asthma attacks for the past 2 months (more than 4 times per week average), serious MVA 10 weeks ago; post traumatic seizure 2 weeks after the accident; anticonvulsant phenytoin started – no seizure activity since initiation of therapy. Treatment tried Theophylline SR Capsules 300 mg PO BID, Albuterol inhaler, PRN, Phenytoin SR capsules 300 mg PO QHS, HTCZ 50 mg PO BID, Enalapril 5 mg PO BID. PMH: P.E has history of periodic asthma attacks since early 20s; mild congestive heart failure diagnosed 3 years ago; placed on sodium restrictive diet and hydrochlorothiazide; last year placed on Enalapril due to worsening CHF; symptoms well controlled the last year. Past Surgical History: Serious MVA 10 weeks ago. Social/Personal History: Family: Father died age 59 of kidney failure secondary to HTN; Mother died age 62 of CHF Social: Nonsmoker; no alcohol intake; caffeine use: 4 cups of coffee and 4 diet colas per day. Medication History: Theophylline SR Capsules 300 mg PO BID Albuterol inhaler, PRN Phenytoin SR capsules 300 mg PO QHS HTCZ 50 mg PO BID Enalapril 5 mg PO BID Allergies: NKDA. Review of Symptoms: General: Pale, well developed female appearing anxious. HEENT: PERRLA, oral cavity without lesions, TM without signs of inflammation, no nystagmus noted. Cardio: Regular rate and rhythm normal S1 and S2. Chest: Bilateral expiratory wheezes. Abdomen: soft, non-tender, non-distended no masses. GU: Unremarkable. Rectal: Guaiac negative. EXT: +1 ankle edema, on right, no bruising, normal pulses. NEURO: A&O X3, cranial nerves intact. Objective Data: Vital Signs including BMI: BP 171/94 mmhg HR 122 RR 31x’ T 96.7 F. Wt 145, Ht 5’ 3” BMI: 25.7 (Overweight) VS after Albuterol breathing treatment – BP 134/79, HR 80 x’, RR 18 x’ Physical Assessment Findings: Positive for shortness of breath, coughing, wheezing and exercise intolerance. Pale, well developed female appearing anxious. HEENT: PERRLA, oral cavity without lesions, TM without signs of inflammation, no nystagmus noted. Cardio: Regular rate and rhythm normal S1 and S2. Chest: Bilateral expiratory wheezes. Abdomen: soft, non-tender, non-distended no masses. GU: Unremarkable. Rectal: Guaiac negative. EXT: +1 ankle edema, on right, no bruising, normal pulses. NEURO: A&O X3, cranial nerves intact. HEENT: Normal. Lymph Nodes: absent. Carotids: Normal, not bruit Lungs: Bilateral expiratory wheezes. Heart: Tachycardia, Regular rate and rhythm normal S1 and S2. Abdomen: soft, non-tender, non-distended no masses. Genital/Pelvic: Unremarkable. Rectum: Guaiac negative. Extremities/Pulses: +1 ankle edema, on right, no bruising, normal pulses. Neurologic: A&O X3, cranial nerves intact. PERRLA Lab Tests and Results: Na – 134 (Low) K – 4.9 (Normal) Cl – 100 (Normal) BUN – 21 (Normal) Cr – 1.2 normal Glu – 110 (Normal) ALT – 24 (High) AST – 27 (High) Total Cholesterol – 190 (Borderline ) CBC – WNL Theophylline – 6.2 (Normal limits) Phenytoin – 17 (Normal limits) Chest X-ray – Blunting of the right and left Costophrenic angles: Abnormal Peak Flow – 75/min; after albuterol – 102/min: (Low Peak Flow, and good response to albuterol). FEV1 – 1.8 L FVC 3.0 L FEV1/FVC 60% – (Air way obstruction) ICD-10 Diagnoses/Client Problems: 1. – J45.901 Unspecified asthma with (acute) exacerbation 2. – J45.41 Moderate persistent asthma with (acute) exacerbation 3. – V89.2XXA unspecified motor-vehicle accident. 4. – R56.1. Post traumatic seizures. 5. – I50.20 unspecified systolic (congestive) heart failure. Advanced Practice Nursing Intervention Plan: After reviewing the patient, PMH, Physical Assessment Findings and lab results for P.E there are a few areas of concern to note in her health assessment. But I have to focus in the main patient health problem: Moderate persistent asthma with (acute) exacerbation.  Asthma is a chronic disease that continues to be a serious public health problem. It has been estimated that a total of 39.5 million of people had been diagnosed with asthma in Unite State. In response to the problems the population has been faced with asthma, the Center for Disease Control and Prevention (CDC) launched the National Asthma Control Program (NACP) (Center of Disease Control and Prevention, 2013). In Florida more than 2.6 million of adults and children have lifetime asthma, and approximately 1.6 million had current asthma in 2012. The number of people with asthma that visit emergency department has increased in the past five years. Non-Hispanic black Floridians had the highest Emergency Department visit and hospitalization rates. In Florida the collaborative practices are established between state, local public health and the different health institutions, with the objective to provide better care to patients with asthma. Primary health cares (MD, PA, APRN) has the responsibility to develop an individualized an action plan to ensure that the patient understands daily medication, avoid asthma triggers, and how identify warning signs that require quick-relief medications (Scott, & Armstrong, 2013). Inhaled Corticosteroids (ICs) are the most effective controllers for asthma, and their early use has revolutionized asthma therapy. This type of drugs reduces the number of inflammatory cells and their activation in the airways. ICs reduce eosinophils in the airways and the sputum, and the numbers of activated T lymphocytes and surface mast cell in the airway mucosa. Its major effect is to switch off the transcription of multiple activated genes that encode inflammatory proteins (Fauci et al, 2008). Inhaled Corticosteroids are usually given twice a day. ICs rapidly improve the symptoms of asthma, and lung function improves over several days. They are effective in preventing asthma symptoms, such as exercise-induced asthma and nocturnal exacerbation, but also prevent severe exacerbation. ICs reduce airway hyperresponsiveness (AHR), but maximal may take several months of therapy. Early treatment prevents irreversible change in airway function that occurs with chronic asthma. Withdrawal of ICs results in slow deterioration of asthma control, indicating that they suppress inflammation and symptoms but do not cure the underlying condition. ICs are given as a first-line therapy for patients with persistent asthma. In case that the symptoms are no control in low doses, it is usually to add a long-acting inhaled Beta 2 agonists (LABA) (Fauci et al, 2008). Inhaled Corticosteroids: (as cited by Lacy, Armstrong, Goldman, Lance, 2010, p. 1847) Beclomethasone Budesonide and Formoterol Ciclesonide Fluticasone Mometasone Triancinolone Local side effects of inhaled corticosteroids are dysphonia, oropharyngeal candidiasis, and cough. On the other hand, systemic side effects of inhaled corticosteroids include adrenal suppression and insufficiency, bruising, osteoporosis, growth suppression, cataracts, glaucoma and pneumonia. Other side effects are metabolic abnormalities relating to glucose, insulin, and triglycerides. Additionally, the patient may have psychiatric disturbances such as euphoria and depression (Brunton, Chabner, Knollman, 2011). Our goals in the asthma treatment is to prevent and troublesome symptoms. To ensure that patients do not have limitations in their activities. Achieving the minimum use of short-acting beta-agonist. It is also important the patient be free from side effects of medications or hat these are minimum. Maintain lung function as close to normal and prevent recurrent exacerbations (Lacy, Armstrong, Goldman, Lance, 2010). A peak flow meter is an easy portable device that measures lung function. Patients suffering from asthma can use this device to track their progress.  The purpose of this exercise is to identify the peak flow zones of the patient so that a coded system based on results and patient symptomatology can be established to adjust appropriate asthma interventions. (McCance & Huether, 2014). There are three peak flow zones and they are determined by the peak flow rate and symptoms. The green zone is a peak flow rate between 80 to 100 percent, and is equivalent to stable. Typically, there should be no signs or symptoms of asthma and the patient should continue to take preventive medication. The yellow zone is a peak flow rate between 50 to 80 percent, and it indicates that the patient should be cautious and might need to change or increase asthma medication. A patient in the yellow zone may have signs and symptoms of asthma such as chest tightness, coughing, and wheezing. The red zone is a peak flow meter of 50 or less percent and it indicates danger of a medical emergency. The patient might have severe shortness of breath, wheezing and coughing. It is recommended for the patient to seek emergency care (Mayo Clinic, 2014).  Additional treatment considerations include the following: Recognized the exacerbating effects of environmental factors such as allergens, air pollution, smoking, and weather (cold and humidity). Use potential medication exacerbating with caution (Aspirin, NSAIDs, and Beta Blockers). Always consider medication compliance and technique as possible complicating factors in poorly controlled asthma. Treatment of coexisting condition (Rhinitis, sinusitis, GERD), may improve asthma. Follow-up: The follow-ups in 3-5 days. References McCance, K. L., Huether, S. E., Brashers, V. L., & Rote, N. S. (2014). Pathophysiology: The biologic basis for disease in adults and children (7th ed.). St. Louis, MO: Mosby. Brunton, L. , Chabner, B. , Knollman, B. , 2011). Goodman & Gilman’s. The pharmacological basis of therapeutics (12th ed.) New York, NY: McGraw Hill Fauci, A. , Braunwald, E. , Kasper, D. , Hauser, S. , Longo, D. , Jameson, J. L. , Loscalzo J. (2008). Harrison’s. Principles of internal medicine. (17th ed.) New York, NY: McGraw Hill Lacy, C. F., Armstrong, L. L., Goldman, M. P., Lance, L. L. (2010). Drug information handbook (19th ed.) Hudson, OH: Lexi-Comp APhA. Mayo Clinic (2014). Test and procedure. Peak flow meter. Retrieve from http://www.mayoclinic.org/tests-procedures/peak-flow-meter/basics/results/prc-20013057 Scott, R. , & Armstrong, J. H. (2013). Burden of asthma in Florida. Florida Health. Retrieves from http://www.floridahealth.gov/diseases-and-conditions/asthma/_documents/asthma-burden2013.pdf
SOAP Note AssignmentClick 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. Yo
Running head: NAME OF CARE PLAN 1 Title of Plan of Care NameSouth University Online Faculty Name NSG 6001Date NAME PLAN OF CARE 2 **Please delete this statement and anything in italics prior to submission to shorten the length of your paper. Patient Initials ______Subjective Data: (Information the patient tells you regarding themselves: Biased Information): Chief Compliant: (In patient’s exact words) History of Present Illness: (Analysis of current problems in chronologic order using symptom analysis [onset, location, frequency, quality, quantity, aggravating/alleviating factors, associated symptoms and treatments tried]). PMH/Medical/Surgical History: (Includes medications and why taking, allergies, other major medical problems, immunizations, injuries, hospitalizations, surgeries, psychiatric history, obstetric and history sexual history). Significant Family History: (Includes family members and specific inheritable diseases). Social History: (Includes home living situation, marital history, cultural background, health habits, lifestyle/recreation, religious practices, educational background, occupational history, financial security and family history of violence). Review of Symptoms: (Review each body system – This section you should place POSITIVE for… information in the beginning then state Denies…). – General:; Integumentary:; Head:; Eyes: ; ENT:; Cardiovascular:; Respiratory: ; Gastrointestinal:; Genitourinary:; Musculoskeletal:; Neurological:; Endocrine:; Hematologic:; Psychologic: . Objective Data:Vital Signs: BP – ; P ; R ; T ; Wt. ; Ht. ; BMI .Physical Assessment Findings: (Includes full head to toe review)HEENT:Lymph Nodes:Carotids:Lungs:Heart:Abdomen:Genital/Pelvic:Rectum:Extremities/Pulses:Neurologic:Laboratory and Diagnostic Test Results: (Include result and interpretation.) Assessment: (Include at least 3 priority diagnosis with ICD-10 codes. Please place in order of priority.) Plan of Care: (Addressing each dx with diagnostic and therapeutic management as well as education and counseling provided). NAME PLAN OF CARE 3 References
SOAP Note AssignmentClick 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. Yo
Week 2: Respiratory Clinical Case Patient Setting: 65 year old Caucasian female that was discharged from the hospital 10 weeks ago after a motor vehicle accident presents to the clinic today. States she is having severe wheezing, shortness of breath and coughing at least once daily. She can barely get her words out without taking breaks to catch her breath and states she has taken albuterol once today. HPI Frequent asthma attacks for the past 2 months (more than 4 times per week average), serious MVA 10 weeks ago; post traumatic seizure 2 weeks after the accident; anticonvulsant phenytoin started – no seizure activity since initiation of therapy. PMH History of periodic asthma attacks since early 20s; mild congestive heart failure diagnosed 3 years ago; placed on sodium restrictive diet and hydrochlorothiazide; last year placed on enalapril due to worsening CHF; symptoms well controlled the last year. Past Surgical History None Family/Social HistoryFamily: Father died age 59 of kidney failure secondary to HTN; Mother died age 62 of CHF Social: Nonsmoker; no alcohol intake; caffeine use: 4 cups of coffee and 4 diet colas per day. Medication HistoryTheophylline SR Capsules 300 mg PO BID Albuterol inhaler, PRNPhenytoin SR capsules 300 mg PO QHS HTCZ 50 mg PO BID Enalapril 5 mg PO BID AllergiesNKDAROS Positive for shortness of breath, coughing, wheezing and exercise intolerance. Denies headache, swelling in the extremities and seizures. Physical examBP 171/94, HR 122, RR 31, T 96.7 F, Wt 145, Ht 5’ 3”VS after Albuterol breathing treatment – BP 134/79, HR 80, RR 18 Gen: Pale, well developed female appearing anxious. HEENT: PERRLA, oral cavity without lesions, TM without signs of inflammation, no nystagmus noted. Cardio: Regular rate and rhythm normal S1 and S2. Chest: Bilateral expiratory wheezes. Abd: soft, non-tender, non-distended no masses. GU: Unremarkable. Rectal: Guaiac negative. EXT: +1 ankle edema, on right, no bruising, normal pulses. NEURO: A&O X3, cranial nerves intact. Laboratory and Diagnostic Testing Na – 134K – 4.9Cl – 100 BUN – 21Cr – 1.2Glu – 110ALT – 24AST – 27Total Chol – 190 CBC – WNL Theophylline – 6.2 Phenytoin – 17 Chest Xray – Blunting of the right and left costophrenic angles Peak Flow – 75/min; after albuterol – 102/minFEV1 – 1.8 L; FVC 3.0 L, FEV1/FVC 60%

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