NURS 6540N-4: Practicum - Week 3 SOAP Note: Advanced Practice Care of Adults, Exams of Nursing

Download NURS 6540N-4: Practicum - Week 3 SOAP Note: Advanced Practice Care of Adults and more Exams Nursing in PDF only on Docsity! Practicum - Week 3 SOAP Note Walden University Advanced Practice Care of Adults NURS 6540N-4 Dr. September 23, 2018 2PRACTICUM - WEEK 3 SOAP NOTE Practicum - Week 3 SOAP Note Internal Medicine - Admission consultation for medical management and treatment Patient Initials: P.A. Age: 81 yrs. Sex: Female Race: Caucasian SUBJECTIVE CC: "I'm worried about all these urinary tract infections." HPI: P.A. is an 81year old female with a recent history of recurrent UTIs, CHF, HTN, CVA/TIA, COPD with chronic use of O2, and Barrett's esophagus who admitted to the rehabilitation hospital on 9/7/2018 due to ambulatory dysfunction secondary to urinary tract infection. The patient initially presented to the ED on 9/6/2018 complaining of back pain, generalized weakness, and dysuria. She had recently been hospitalized and then discharged to an acute rehabilitation hospital for UTI and ambulatory dysfunction. She had completed a course of PO Levaquin one day prior to being discharged home from rehab. She had been doing well initially, but 3 days prior to presenting to the ED, the patient developed increasing urinary urgency, dysuria, and back pain. She also noted right abdominal pain and RLE pain. No nausea or vomiting, no change in bowel movements, no chest pain or palpitations, SOB, HA or change in vision reported. In ED vital signs were stable and the patient afebrile. She was subsequently admitted to inpatient status and started on Levaquin 750mg IV since the last urine culture on 8/19 had grown Klebsiella, sensitive to Levofloxacin. She remained afebrile with stable vital signs through the hospitalization. No acute abnormalities were seen on head CT. CXR showed persistent increased opacity in bilateral lower lungs, could be atelectasis or infiltrates and additionally persistent hypoinflation of lungs. The patient's clinical disposition gradually improved, but she continued to have ambulatory dysfunction and generalized deconditioning. She was felt to be a good candidate for aggressive inpatient rehabilitation, so she was referred to HealthSouth Rehabilitation Hospital for comprehensive rehab. Today, the patient was evaluated in her room at the bedside, sitting up in a chair, O2 NC at 2 l/min. She states she has a good appetite, is moving her bowels and typically takes MiraLAX at home with applesauce and prune juice to keep her bowels regular. Voiding without any complaints or concerns, drinking fluids. She is very concerned about her recurrent UTIs. So far, tolerating rehab therapies. No acute medical concerns reported otherwise by nursing staff. Medications: 1.) Coreg 3.125 PO, BID with meals 2.) Lovenox syringe 40mg SC, once a day 3.) Folvite 1mg PO, once a day 4.) Lasix 20mg PO, once a day 5.) Humalog injection 4 units SC, AC & HS 6.) Levaquin 750mg IV, Q 24h PRACTICUM - WEEK 3 SOAP NOTE 5 fatigue PSYCHIATRIC: Denies recent mood change. She denies any change in sleep habits PRACTICUM - WEEK 3 SOAP NOTE 6 NEURO: No light-headedness, dizziness, tremor, or syncope HEENT: She denies changes in vision or unusual headaches. No sore throat or difficulty swallowing SKIN: No new rashes or skin changes, thinning hair, or brittle nails CARDIOVASCULAR: Legs with chronic swelling bilaterally, states compression wraps, and stockings do not work for her. No chest pain, pressure, dizziness, or palpitations RESPIRATORY: States occasional chronic cough. Uses home O2 by NC. Denies waking at night with cough or choking. No shortness of breath, no wheezing or sputum production GASTROINTESTINAL: Occasional constipation, uses Miralax and prune juice to stay regular. Denies decreased appetite. No nausea, vomiting, jaundice, diarrhea, black or bloody stool. No abdominal pain or bloating. GENITOURINARY: No pain with urination, incontinence, frequency, or urgency. No blood in urine. MUSCULOSKELETAL: Denies muscle weakness. No tenderness in extremities, no joint or back pain. No change in mobility. OBJECTIVE VS: T 36.1 BP 114/53 HR 54 RR 20 O2Sat 93% Height 5'3" Weight 252lbs BMI 44 Physical Exam: General - Nontoxic appearance, pleasant, obese elderly female. No acute distress. Mental Status - Has appropriate affect, judgment, and insight. Displays no anxiety. She was able to appropriately the draw face of a clock with numbers and time at 11:20 Skin - Pink, warm, dry, well-perfused. Skin color, texture, and normal skin turgor and age appropriate. No cyanosis or clubbing. No rashes or open lesions HEENT - Atraumatic and normocephalic, no deformities. Hearing is grossly intact. Facial features symmetric. No pitosis, erythema, or swelling. Sclera nonicteric. Mucous membranes are moist. No hoarseness, tongue is midline. Sinuses are non-tender. Neck/Lymphatic - Supple, without masses, tenderness, or enlargement of cervical lymphnodes. No carotid bruits Chest/Lungs - Equal chest expansion. Chest is symmetrical with normal AP diameter. No cough, sputum production, or wheezing. Normal respiratory effort on 2l/min O2 NC, no crackles, clear vesicular breath sounds bilaterally. Breast exam deferred. Heart/Peripheral Vascular - S1S2, regular rhythm. No rub, murmur, or gallops appreciated. No JVD, peripheral pulses +2 x4 extremities. Abdomen - Soft, non-tender, obese, non-distended abdomen with no masses or pulsations. Bowel sounds normoactive x4 quadrants. No suprapubic tenderness, no inguinal lymphadenopathy. No hepatosplenomegaly appreciated. Genital/Rectal - deferred Musculoskeletal - Able to move all four extremities against gravity, strength 3-4/5 bilaterally. No swollen joints. BLE with thick fibrotic woody edema. Neurological - PERRL. Cranial nerves II-XII grossly intact. Sensation intact x4 extremities. Coordinated movements. Speech is clear. She has good comprehension and recall. Lab and Diagnostic Results: PRACTICUM - WEEK 3 SOAP NOTE 7 9/6/18 NA 139, K+4, Cl- 100, CO2 29.3, BUN16, Cr 0.95, Ca 9.1, WBC 8.2, RBC 3.74, Hgb 9.3, Hct 29.2, Plt 395. 9/2018 CT of the head -No acute abnormalities 9/2018 CXR showed persistent increased opacity in bilateral lower lungs, could be atelectasis or infiltrates and additionally persistent hypo inflation of lungs. 2/23/18 Echocardiogram - Grade 1 left ventricular diastolic dysfunction. Normal ejection fraction, EF 55-60%. Trace mitral valve regurgitation. Mild to moderate tricuspid valve regurgitation. ASSESSMENT Differential Diagnoses: 1.) Recurrent Urinary Tract Infection (UTI) - The pathogenesis of recurrent urinary tract infection should be considered as a separate disorder from the initial infection (Jhang & Kuo, 2017). Two mechanisms may be involved including bacterial factors and host defense deficiencies. Rather than only treating the recurrent UTI with only antibiotics, current evidence and guidelines point to aggressive management to address the distinct disorder of recurrent UTIs (Jhang & Kuo, 2017). The latest guidelines suggest that preventive efforts do not support the use of cranberry juice, probiotics, but do support the use of intravaginal estrogen therapy, oral or parenteral vaccines, and continuous antimicrobial prophylaxis (Jhang & Kuo, 2017). 2.) Atrophic vaginitis (AV) - Postmenopausal women frequently have symptoms of vaginal dryness, discomfort, and dyspareunia associated with AV. These symptoms along with urinary and genital changes are caused by decreased estrogen levels after menopause (Lee, Kim, Lee, Kim, Enkhbold, Lee, & Song, 2018). These symptoms are more common in patients with diabetes mellitus and may be caused by infection. Klebsiella and Escherichia coli are commonly found pathogens in vaginitis (Razzak, Al-Charrakh, & AL-Greitty, 2011). Ospemifene has demonstrated the greatest therapeutic effects on cellular changes as well as relieving the associated symptoms (Lee, Kim, Lee, Kim, Enkhbold, Lee, & Song, 2018). 3.) Overactive bladder (OAB) - Urinary urgency, frequency, and nocturia with or without incontinence are the hallmarks of OAB (Willis-Gray, Dieter, & Geller, 2016). The disorder can lead to skin breakdown, falls, prolonged hospitalization, and lower quality of life for many. These patients have 21% more UTIs and 84% more physician visits each year. Age is the most common risk factor (Willis-Gray, Dieter, & Geller, 2016). A thorough history and physical examination and additional laboratory studies are necessary to make a diagnosis (Willis-Gray, Dieter, & Geller, 2016). Diagnoses/Patient Problems: 1.) Ambulatory Dysfunction 2.) Urinary Tract Infection 3.) COPD on chronic O2 4.) Diabetes Mellitus type 2 5.) Chronic diastolic CHF 5.) Hypertension 5.) Hypothyroidism 1 0 PRACTICUM - WEEK 3 SOAP NOTE Reflection Notes Providing an admission consultation for medical management requires a lot of time to review the patient's history for the internal medicine provider. This patient provided me an opportunity to review, examine, and plan for this patient as well as write the complete SOAP consultation. My preceptor worked through all the details of the documentation, and this is what she feels is complete and thorough. It was an exciting process, but very time- consuming. She assured me it would get easier. I used the Beers criteria to evaluate the appropriateness of medical management. This patient was not taking more than six medications prior to her recent hospitalization. Several of her medications will be stopped prior to discharge, including Lovenox, Hydrocodone, and the Levaquin IV. Functional assessments were used for this patient's admission process. Physiatry managed the majority of these and provided documentation on all parameters. The assessments included the Katz Index ADL scale, NHP questionnaire, and the Care Dependency Scale for assessing needs. When I examined the patient, I used the mini-cognitive assessment instrument. The patient scored normal for recall, normal for clock drawing, and negative for dementia. In a similar patient evaluation, I plan on taking an additional step in the workup and exam. Regarding interprofessional collaboration, my consultation and management plan will be more efficient if I briefly met the physiatry provider and primary nurse prior to meeting the patient for the first time. In my practicum setting, both are available for feedback and additional insight. This communication is usually done through the EMR or only when there is an immediate need. I believe direct one-on-one communication would provide focused insight. With this information, improved individualization of the patient plan can be done on admission. 1 1 PRACTICUM - WEEK 3 SOAP NOTE References Jhang, J.-F., & Kuo, H.-C. (2017). Recent advances in recurrent urinary tract infection from pathogenesis and biomarkers to prevention. Tzu-Chi Medical Journal, 29(3), 131–137. http://doi.org/10.4103/tcmj.tcmj_53_17 Lee, A., Kim, T. H., Lee, H. H., Kim, Y. S., Enkhbold, T., Lee, B., & Song, K. (2018). Therapeutic Approaches to Atrophic Vaginitis in Postmenopausal Women: A Systematic Review with a Network Meta-analysis of Randomized Controlled Trials. Journal of Menopausal Medicine, 24(1), 1–10. http://doi.org/10.6118/jmm.2018.24.1.1 Razzak, M. S. A., Al-Charrakh, A. H., & AL-Greitty, B. H. (2011). Relationship between lactobacilli and opportunistic bacterial pathogens associated with vaginitis. North American Journal of Medical Sciences, 3(4), 185–192. http://doi.org/10.4297/najms.2011.3185 Willis-Gray, M. G., Dieter, A. A., & Geller, E. J. (2016). Evaluation and management of overactive bladder: strategies for optimizing care. Research and Reports in Urology, 8, 113–122. http://doi.org/10.2147/RRU.S93636