NURS 5304 Soap Note of Mrs S

NURS 5304 Soap Note of Mrs S

Student Name: James Hare__________________________  Date: _06/18/20______________

Name (Initials only) MS Date 06/04/2019 Time 0838
DOB 8/27/1977 Sex F
HISTORY (Subjective  S)
Chief Complaint: Ms. S is a 41 year old female arrived today for Well Women’s Check up and is complaining of swelling in legs.
HPI: Patient stated “I was just recently hospitalized for D&C (miscarriage at 17 weeks), anemia which required 4 units of packed red blood cells, and nephrotic syndrome.” Anemia and hypertension were first diagnosed two years ago. Her current cardiac medication regimen includes a diurectic, a calcium channel blocker, and ferrous sulfate. Medical problems to be addressed today include hypertension, diabetes and iron deficiency anemia. She is here for her Well Women’s check up and lab work. Of note, Pt has appointment w/ Dr. Chu on the 18th for kidney bx and follows Dr. Michael for OB/GYN and has appointment with her on the 10th to follow up after the D&C in the hospital.Ms S does not check her blood pressure other than at her clinic appointments. She has been experiencing possible adverse medication effects including dizziness (intermittently). Compliance with treatment has been fair; she does not follow a diet and exercise plan.

Concerning iron deficiency anemia, the patient is known they are anemic for 12 months now. The patient has iron deficiency anemia. She denies excessive bruising, melena, and Epistaxis. Medical history is significant for iron deficiency anemia.

Dx with type 2 diabetes mellitus with hyperglycemia; specifically, this is type 2, non-insulin requiring diabetes without complications. Compliance with treatment has been fair; she does not follow a diet and exercise regimen. Pt diabetes was first diagnosed 2 years ago. She follows no particular diet. She denies any diabetes related symptoms.

She reports home blood glucose readings have been fairly good, with average fasting glucose running in the 120-150 mg/dL range. She checks her glucose 2 times per day. Blood pressure has been normal and well controlled. In Regard to preventative care, she performs foot care self exams daily, her last ophthalmology exam was > 1 year ago, and Last PAP was 2 years ago. She states that she has not had any abnormal PAPs in the past.

Medications Drug Information/Rationale for use
Bumetanide 1 mg tablet, take 1 tablet by mouth twice a day Class: Loop DiureticTaking: management of fluid retention

Normal Range: 0.5-2 mg once daily, may repeat in 4-5 hours up to two doses not to exceed 10mg/day

MOA: Inhibits reabsorption of sodium and chloride from the loop of Henle and distal renal tubule. Increases excretion of water, sodium, chloride, calcium, magnesium, potassium, and hydrogen ions.

Drug-Drug interaction: Increased risk of hypotension with antihypertensive, nitrates, or acute ingestion of alcohol. Increase risk of hypokalemia with other diuretics, amphotercin B, stimulant laxatives and corticosteroids.

Drug-Food: consult a HCP on a high potassium diet, do not drink alcohol.

Adverse Effects: Dizziness, hypotension, Diarrhea, hypocholoremia, hypokalemia, hyperuricemia.

Monitor:  Monitor daily weight, intake and output ratios, blood pressure, edema amount and location, lung sounds. Notify HCP if thirst, dry mouth, lethargy, weakness, hypotension occurs.

(Vallerand, et.al., 2015 pg. 233-234 NURS 5304 Soap Note of Mrs S)

Januvia 50mg tablet, take 1 tablet by mouth daily Class: Antidiabetic, Deptidase-IV inhibitorTaking: control of type 2 diabetes.

Normal Range: 25,50,100 mg tablets daily

MOA: Dipeptyl peptidase-IV (DDP-IV) inhibitor increases and prolongs incretin hormone activity, which is inactivated by DDP-IV enzyme.  Incretins increase insulin release and synthesizes from pancreatic beta cells and reduce glucagon, secretin from pancreatic alpha cells.

Drug-Drug interactions: may slightly increase serum digoxin levels; monitoring recommended. Increases risk of hyperglycemia when used with insulin, glyburide, glipizide, or glimepiride.

Adverse Effects: headache, pancreatitis, nausea, diarrhea, acute renal failure

Labs: CrCl> 50 mL/minute-no adjustment

CrCl 30-50 mL/minute-50mg/day

CrCl<30mL/minute- 25 mg/day

ESRD: 25 mg/day regardless of hemodialysis.

Monitor: Blood Glucose, HgbA1C

(Vallerand, et.al., 2015, pg.1127)

Procardia XL 30mg tablets, take 1 tablet by mouth daily Class: Calcium Channel BlockerTaking: control of primary hypertension.

Range: Capsule: 10,20mg. Tablet: ER: 30,60,90 mg.

30-60mg by mouth daily; may be increased ever 7-14 days PRN, not to exceed 120 mg/daily.

MOA: inhibits transmembrane influx of extracellular calcium ions across myocardial and vascular smooth muscle cell membranes without changing serum calcium levels, thus results in inhibition of cardiac and vascular smooth muscle contraction and there by dilating main coronary and systematic arteries.

Drug-Drug interactions: Rifampin, rifabutin, Phenobarbital, phenytoin, or carbamazepine may cause significantly decreased levels and effects. Contraindicated with ketoconazole, fluconazole, erythromycin, nefazodone may cause levels to increase and its effects to increase.

Adverse effects: headache, peripheral edema, dizziness, flushing, nausea.

Monitor: blood pressure throughout therapy and pulse before administering medication. Monitor EKG changes, intake and outtake ratios and weight loss or gain. Assess for Heart failure (rales, crackles, peripheral edema, dyspnea, JVD).

(Vallerand, et.al., 2015, pg. 898)

Ferrous Sulfate 325mg tablets, take 1 table by mouth three times a day Class: Iron ProductsTaking:  treatment of iron deficiency anemia.

Range:  45mg, 200mg (65Fe), 300 mg (60Fe), 325 mg (65 Fe).Recommended daily allowance of elemental  iron 19-50 y/o: Female: 18mf/daily.

100mg-200mg PO divided ever 12 hours, may administer extended release daily.

Administration: Take with food or orange juice, may cause stomach ache on empty stomach.

MOA: Replaces iron stores found in hemoglobin, myoglobin, and enzymes, allows transportation of oxygen via hemoglobin.

Drug-Drug interaction: oral iron supplements decrease absorption of tetracyclines, bisphosphates, fluroquinolones, levothyroxine, mycophenolate mofetil and penicillamine and should be avoided.

Drug-Food: food decreases absorption of iron, but does decrease GI irritation as well. Vitamin c will increase absorption.

Adverse effects: Constipation, diarrhea, dark stools, GI irritation, nausea, stomach pain, vomiting.

Monitor: Hemoglobin, Iron, TIBC, and Ferritin during drug therapy.

(Vallerand, et.al., 2015, pg. 709)

Cozaar 50mg tablet, take 1 tablet  by mouth daily Class: ARBTaking: treatment of hypertension and diabetic neuropathy in type 2 diabetics.  Range: 25,50, 100 mg daily. 50 mg/ day (25 mg in patients who are intravascular depleted or receiving diuretics). 25-100 mg/day PO in 1 to 2 doses.

MOA: blocks binding of angiotensin II to type 1 angiotensin II receptors, blocks the vasoconstrictor and aldosterone-secreting effects of angiotensin II.

Drug-Drug interactions: NSAIDS and selective COX-2 inhibitors may blunt the antihypertensive effect and increase the risk of renal dysfunction. Increases antihypertensive effects with other antihypertensive and diuretics.

Decrease in patients with possible intravascular depletion or who are on diuretics.

Adverse Effects: Fatigue, hypoglycemia, anemia, UTI, chest pain, weakness, diarrhea, worsening cough, and angioedema.

Monitor: assess BP and pulse periodically during therapy. Notify provider if significant changes occur. Assess for angioedema (Dyspnea, Facial swelling). Monitor daily weight and assess for fluid overload.

Monitor labs: Renal function, electrolyte levels. Serum potassium, BUN, serum creatinine may be increased.

(Vallerand, et.al., 2015, pg. 170)

No known Drug allergies
PMI: Hyperlipidemia,Hypertension dx in 3/2017

Nephrotic syndrome dx 10/2018

Type 2 diabetes dx in 3/2017

Iron deficiency anemia dx 3/2017

Obesity

Vaccinations: up to date with all vaccinations. Flu 10/2018, Tetanus unknown

PAP SMEAR done 2017 with no abnormalities.

Hospitalizations/Surgeries: Cesarean section x 2, 2001, 2002; Dilation and Curettage 05/2019
Family History (FH): Type 2 Diabetes (Father), Hypertension (Father)
Social History (SH) :Occupation: Bedrock Academy

Marital Status: Married

Children: 2 children

Exercise: Rarely

Smoking: Never

Alcohol: does not drink alcohol

Substance abuse: none

Review of Systems (ROS)  Subjective S
General: Negative for fever, chills, fatigue, night sweats, unintentional weight gain or loss If chills, sweats, fatigue are noted, them this could be a concern for a cardiac event , blood pressure problem, or an adverse effect of Losartan or hypoglycemia
Cardiovascular: Positive for dizziness and pedal edema (Moderate). Negative for chest pain, orthopnea, palpitations or tachycardia. Abnormal changes are a direct result of swelling of the legs and can be cause by her history of primary hypertension (166/96 todays result) or medication ineffectiveness. The dizziness correlates with the effects of consistently high blood pressures. This matches her chief complaint and fits with differential diagnosis of primary hypertension in that the patient is not compliant with exercise, medications, BP monitoring or diet.(Vallerand, et.al., 2015 pg. 233-234 NURS 5304 Soap Note of Mrs S)

(Rhodes & Petersen, 2014)

Respiratory: Negative for recent cough and dyspnea
Gastrointestinal: negative for abdominal pain, heartburn, constipation, diarrhea, stool changes, nausea, vomiting Diarrhea could be an adverse side effect of Losartan if it was noted.
Genitourinary: Negative for dysuria and hematuriaGyn : differed due to recent D&C

LMP: 12/2018

Patient was 17 wks pregnant, but had a miscarriage 5/2019.
Musculoskeletal: Negative for soreness, muscle cramps, joint pain or stuffiness
Neurological: negative for dizziness and headaches
Skin: Positive for pedal edema. Negative for rash, skin breakage, redness, easy bruising Edema present as a result of hospitalization for miscarriage and IV fluid administration (4 units of PRBC, and continuous IV Normal Saline administration) while hospitalized. Also patient is non-compliant with exercise, medication, and diet regimens. This correlates with the primary hypertension diagnosis, as swelling is a direct result of increased BP and mixed Hyperlipidemia in that increased lipids can cause blood pressure to be increased and in turn cause decreased preload or vascular return to the heart and if not treated can lead to right sided heart failure, and increase swelling in the lower extremities.

(Vallerand, et.al., 2015 pg. 233-234)

(Rhodes & Petersen, 2014)

Eyes: Negative for blurred vision
Ears: Negative for hearing problems
Nose/Mouth/Throat: Negative for E/N/T pain, congestion, rhinorrhea, epistaxis, hoarseness, and dental problems
Breast: differed
Mental Health/Developmental:  Negative for anxiety, depression and sleep disturbance
Endocrine: Negative for temperature intolerances, polydipsia and polyphagia
Hematologic/Lymphatic: Positive for blood transfusion while hospitalized. Negative for bruising. Pt received 4 units of blood while hospitalized with a miscarriage and blood loss was a result. The uses of PRBC’s and IV fluid administration caused fluid overload and cause swelling. Also patient has a history of iron deficiency anemia.
PHYSICAL EXAMINATION  Objective O
Weight: 194lbsBMI: 35.5 Temp: 98.6-tympanic BP   Sitting: 166/96-Left armStanding

Lying

Height: 5’2 Pulse:85 Resp: 20, O2 sat 97%RA
General Appearance: 41 y/o female is alert and oriented, with clear speech and is a good historian. she is well dressed, well nourished, no acute distress and is obese.
Skin: Positive for edema from mid calf to feet. Negative for rash, skin breakage, redness, easy bruising.Edema is a result of uncontrolled hypertension (166/96), non-compliance with medication, diet and exercise regimen. Edema also correlates with the diagnosis of primary hypertension. Also edema is a result of IV fluid administration (4 units of PRBC, and continuous IV Normal Saline administration) while hospitalized.

(Vallerand, et.al., 2015 pg. 233-234)

(Rhodes & Petersen, 2014)

HEENTEyes: Clear, PERRLA, no drainage, EOM intact

Ears: TM clear bilaterally, landmarks identified, canal is clear of debris, pink, and dry

Nose: Turbinates are no swollen, no drainage noted, no tenderness noted

Throat: clear with no redness or drainage, tonsils not swollen, and uvula is midline with no deviation

Mouth: gums moist, pink, not breakage noted, tongue is pink and moist, upper palate has no lesion or damage

CardiovascularRate: 85

Rhythm: Rhythm  regular  S1S2 with no murmur noted, no lifts, no heaves

PMI: 5th intercostals space mid clavicular line

Pulses: radial, brachial, femoral, carotid, popliteal, pedal pulses all 2+, Capillary refill is brisk in fingers and toes. 1+ pitting edema bilateral from mid calves down.

Abnormal changes are a direct result of swelling of the legs and can be cause by her history of primary hypertension (166/96 todays result) or medication ineffectiveness. Also patient is non-compliant with exercise, medication, and diet regimens. This correlates with the primary hypertension diagnosis, as swelling is a direct result of increased BP and mixed Hyperlipidemia in that increased lipids can cause blood pressure to be increased and in turn cause decreased preload or vascular return to the heart and if not treated can lead to right sided heart failure, and increase swelling in the lower extremities.

(Vallerand, et.al., 2015 pg. 233-234)

(Rhodes & Petersen, 2014)

Respiratory: Lungs clear to auscultation bilaterally, anterior and posterior with no abnormal breath sounds
Breast: differed
Gastrointestinal: Abdomen is soft, non tender to palpation, bowel sounds present x 4 quadrants and are normoactive, no rebound tenderness
Genitourinary: not assessed
Musculoskeletal: Full ROM in all joints and extremities or swelling or tenderness noted
NeurologicalCN I-XII: all intact with no abnormal findings

DTR: 2+ in all extremities

Mental: Alert and oriented x4, good affect and positive mood. Insight is good.
Other
Lab Tests  List all labs done, identify abnormals- identify clinical significance of each abnormal lab findingComplete Metabolic Panel and Lipid Panel, CBC, iron, TIBC, Ferritin, hgbA1C.  Patient signed a release of medical information form and it was faxed to Willis Knighton Bossier Medical Records department to obtain all labs and procedure preformed while hospitalized.

 

Special Tests/Diagnosticsnone

 

Final Assessment Findings   ASSESSMENT  A
Assessment Finding/Diagnosis Rationale to Support Diagnosis
Essential  (primary) hypertension: I10 History of hypertension and family history of primary hypertension
Iron Deficiency anemia: D50.8 History of anemia and blood loss due to hospitalization and D&C.
Type 2 Diabetes mellitus with hyperglycemia: E11.65 Patient has history of diabetes with fair control
Mixed Hyperlipidemia History of Hyperlipidemia and obesity with BMI 35.5. Diet and exercise not followed.
Nephrotic Syndrome with unspecified morphologic changes:N04.9 Newly diagnosed while in hospital recently
Plan: P
Treatment Plan Rationale to support Treatment Plan
General: Avoid sexual intercourse until seen by Dr. Michael following the D&C at the hospital. It is a good recommendation to avoid sexual intercourse following a traumatic event such as a D&C until properly seen and treated by her OB/GYN. Trauma to any of the reproduction organs now could result in excessive bleeding and further damage.Educate patient on the importance of monthly self-breast exams and patient demonstrated return demonstration during visit

Educate that according to current guidelines, routine PAP smears can be preformed every 3 years in women whose PAP shows no abnormal results (Hawkins, 2016 NURS 5304 Soap Note of Mrs S).

Essential (Primary) Hypertension
Labs: comprehensive Metabolic panel, lipid panelMedications: Prescribed an angiotensin II receptor blocker and refill calcium channel blocker.

Recommendations: avoid pseudoephedrine or other stimulants/decongestants in common cold remedies, perform routine monitoring of blood pressure with home blood pressure cuff, exercise, reduction of dietary salt intake, take medications as prescribed, try not to miss doses, weight loss and stress reduction.

Follow-up: Schedule a follow-up visit if new or worsening symptoms develop. Follow up appointment in 1 week.

Prescriptions: Refill Procardia XL 30mg, 1 tablet daily #90, refill:1

Refill Cozaar 50mg, take 1 tablet daily #90, Refill: 1

Orders: Complete Metabolic Panel sent out to lab

Angiotensin II receptor blocker added to medication regimen because she is not seeing a change in BP with existing medications and needs an extra antihypertensive to help lower her blood pressures.
Iron Deficiency anemia  
Labs: CBC, iron, TIBC, ferritinMedications: Refill ferrous sulfate

Recommendations: take medications a prescribed daily, take with food to decrease stomach issues and orange juice to increase absorption.

Follow-up: Schedule a follow-up visit if new or worsening symptoms develop. Follow up appointment in 6 months.

Prescriptions: Ferrous Sulfate 325mg, take 1 tablet by mouth three times a day # 270. Refill: 1

Orders: Complete (CBC), automated (Hgb, Hct, RBC, WBC, and platelet count) and automated differential WBC count to be sent out to lab

 
Type 2 Diabetes mellitus with hyperglycemia  
Labs: hgbA1CMedications:

Recommendations: instructed in use of glucometer, adherence to a 2000 calorie ADA diet, weight loss, HgbA1C level cheked quarterly, urine microalbumin test yearly, LDL cholesterol test quarterly, annual monofilament test for evaluating sensation in feet, daily foot self-exam, lower blood pressure, yearly dental exams, annual eye exams, need for yearly flu shot, and pneumovax vaccination ever 5 years.

Follow-up: Schedule a follow-up visit if new or worsening symptoms develop. Follow up appointment in 1 week.

Prescriptions:

Orders: Dilated eye exam (send out), collect venous blood sample by Venipuncture (in house), Hgb A1C (Send out), Lipid panel (total cholesterol, HDL, LDL, triglycerides) (Send out)

 
Mixed hyperlipidemia  
Labs:Medications:

Recommendations: exercise, low cholesterol/low fat diet, and weight loss. Continue to hold statin for now

Follow-up:  Follow up appointment in 3 months.

Prescriptions:

 

 
Nephrotic Syndrome with unspecified morphologic changes  
Labs:Medications:

Recommendations: Avoid NSAIDS, Avoid nephrotoxic medications,  and keep scheduled appointment with Dr. Chu on the 18th. NURS 5304 Soap Note of Mrs S

Follow-up:

Prescriptions:

 

 
 

NURS 5304 Soap Note of Mrs S References

Hawkins, J. W., Roberto-Nichols, D. M., & Stanley-Haney, J. L. (2016). Guidelines for nurse practitioners in gynecologic settings. New York, NY: Springer Publishing Company, LLC. https://www.springerpub.com/guidelines-for-nurse-practitioners-in-gynecologic-settings-9780826173263.html

Hollier, A. (2016). Clinical guidelines in primary care (2nd ed.). Lafayette, LA, Advanced Practice Education Associates.

Rhodes, J., & Petersen, S. W. (2014). Chapter 10: Cardiovascular Disorders. In Advanced Health Assessment and Diagnostic Reasoning (Second ed., pp. 255-256). Burlington, MA: Jones and Bartlett Learning.

Vallerand, A. H., Sanoski, C. A., Deglin, J. H., & Mansell, H. G. (2015). Davis drug guide for nurses. Philadelphia, PA: F.A. Davis Company.