NRNP 6540 Week 2 SOAP Note Paper

NRNP 6540 Week 2 SOAP Note Paper

Advance Practice Care of Frail Elders

SOAP NOTE

Patient Information:

BW, 67 YO, Female, AA

Subjective: (S)

Chief Complaint (CC): Forgetfulness

History of Present Illness (HPI):

BW is a 67 YO, female, AA who is brought in today by her daughter with increased forgetfulness, confusion, lack of short-term memory and inappropriate laughing which has gotten progressively worse recently. She has a history of hypertension, hyperlipidemia, and osteoporosis which are controlled with medication. She denies any vision changes, dizziness, headaches, or vertigo.

She reports osteoporosis but denies pain able to ambulate without assistance or medical devices. She denies any pain traveling down her legs. She does report that her pain is increased with activity. She reports her pain as 2/10 on the numeric pain scale. She denies any fever, chills, nausea, vomiting, pain with urination, hematuria, foul smelling urine, urinary frequency or urgency.

NRNP 6540 Week 2 SOAP Note Paper

BW is alert, cooperative with today’s clinical interview. Her eye contact is fair. Speech is clear and coherent but tangential at times. She makes no unusual motor movements and demonstrates no tics. She denies any visual or auditory hallucinations. She denies any suicidal thoughts or ideations. She is alert and oriented to person, partially oriented to place but is disoriented to time and place. (She reported that she thought was headed to work but “wound up here,” referring to your office, at which point she begins to laugh it off.) She denies any falls or pain. Daughter states symptoms have become more frequent and more prevalent. NRNP 6540 Week 2 SOAP Note Paper

Medications:

  • Amlodipine 10mg PO daily: since 2010, for HTN
  • HCTZ 5mg PO daily: since 2010, for HTN
  • Multivitamin tabs one PO daily: since 2000
  • Atorvastatin 40mg PO qhs: since 2010, for hyperlipidemia
  • Alendronate 70mg PO once a week: since 2018, for post-menopausal osteoporosis

Allergies:

  • Penicillin: hives;
  • Lisinopril: cough, headache,
  • No food, environmental, or seasonal

Past Medical History (PMH):

Daughter states all immunizations are current. Had first pneumonia vaccine in 2018 when she turned 65 YO, annual influenza in October and Tdap booster. Denies past major illnesses or surgeries.

Social and Substance Hx:

BW is a retired teacher who retired at age 65. She enjoys yard work, is active in her church and occasionally volunteers in the local food bank. Denies ever smoking or alcohol use. Denies any illicit drug use. Has lived with her daughter for the last four years since her husband passed away. Daughter states she has no weapons in the home, has a working smoke alarm on each floor of her home, and affirms her mother always wears her seatbelt in the care.

However, hasn’t been driving for the past year due to concerns with her memory lapses. Doesn’t have a cell phone but occasionally uses her laptop.

Family Hx:

Denies any illnesses with possible genetic predisposition, contagious, or chronic illnesses. O family history of Sickle Cell crisis or traits. No siblings. Parents have been deceased since childhood from MVA. Maternal and paternal grandparents are all deceased, from unknown reasons. Has one daughter, alive and well and one granddaughter alive and well.

Surgical Hx:

No prior surgical procedures.

Mental Hx:

No history of delirium, anxiety, or depression. Current concerns are forgetfulness and progressing mental status changes. No history of self-harm practices and/or suicidal or homicidal ideation.

Violence Hx:

No concern or issues about safety. Feels safe in her home with her daughter and son-in-law. In a low crime rate area.

Reproductive Hx:

One daughter, spontaneous vaginal delivery at term, no STD’s. Not sexually active at this time. Natural menopause at 55 YO.

Review of Symptoms (ROS):

General: Generally, in good health. Denies fatigue, fever, chills, night sweats, or weakness. No recent weight gain or weight loss.

HEENT:

  • Head: Atraumatic, normocephalic, no lumps, bumps or
  • Eyes: No visual loss, blurred vision, double vision or yellow
  • Ears, Nose and Throat: No hearing loss, ear pain or ringing to ears, sneezing, congestion, runny nose, or sore throat dysphagia or

Respiratory: Denies cough, sputum production, shortness of breath, or difficulty breathing with exertion.

Cardiovascular/Peripheral Vascular: No chest pain or discomfort, denies palpitations, denies history of heart murmurs, arrhythmias, or edema to lower extremities.

Neurological: Complains of forgetfulness, advancing confusion and cognitive changes. Allergic/Immunologic: Allergic to penicillin and lisinopril. No autoimmune or deficiencies in immune system. Skin: No rash or itching.

Gastrointestinal (GI): No anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood. Genitourinary (GYN): No burning on urination. Post-menopausal: last menstrual period (LMP), 01/01/2010. Musculoskeletal: No muscle, back pain, joint pain or stiffness.

Hematologic: No anemia, bleeding or bruising.

Lymphatics: No lymphadenopathy. No history of splenectomy.

Psychiatric: Forgetful. Increase in cognitive dysfunction. MMSE score of 18/30. No history of depression or anxiety.

Endocrinologic: No reports of sweating, cold or heat intolerance. No polyuria or polydipsia.

Objective

Focused Physical Exam:

Vital signs: B/P-128/76, P-94, T- 97.5, RR-14, SPO2-98%, Wt.-182.8kg, Ht- 66in., BMI-29.50.

General: A&O x3, NAD noted, appears well groomed. Patient is calm and cooperative.

Neuro: MMSE score of 18/30. Primary deficits in orientation, registration, attention, calculation and recall. Lungs: Lung sounds CTA, equal rise and fall of chest bilaterally.

Heart/Peripheral Vascular: RRR without murmur, gallop, or rub. S1 and S2 present, no S3. No swelling to lower extremities. 2+ bilateral radial and pedal pulses.

Diagnostic Results:

  1. Chest X-Ray (CXR): No cardiopulmonary findings
  2. CT Head: Diffuse cerebral atrophy
  3. MMSE: BW scored 18 out of 30 with primary deficits in orientation, registration, attention and calculation, and recall. This score suggests moderate

Assessment

Differential Diagnoses:

  1. Dementia, moderate (presumptive diagnosis), possible Alzheimer’s disease (Laske and Stephens, 2018).

MMSE score of 18 out of 30 suggests moderate dementia (Mini-Mental Status Examination [MMSE]) However, a study by Pedraza, Clark, O’Bryant, et al. (2012) in the Journal of American Geriatrics, concluded that age, dementia severity at study entry, and quality of educational experience were important explanatory factors in understanding existing discrepancies in MMSE performance between Caucasian and African-American adults.

These findings support the use of unadjusted MMSE scores when screening older African Americans for dementia, with an unadjusted MMSE cut score of 22/23 which yielded optimal classification accuracy.

Pathological changes due to Alzheimer’s disease (AD) may occur from two to five, or even ten, years before symptoms of cognitive impairment occur (Kennedy-Malone, Martin-Plank, and Duffy (2019). The Alzheimer’s Association Report (2020 NRNP 6540 Week 2 SOAP Note Paper) further states that detecting mild cognitive impairment (MCI) due to Alzheimer’s Disease early provides an opportunity to begin management that may help preserve existing function as long as possible.

  1. Hypertension
  2. Hyperlipidemia

The U.S. Preventive Services Task Force (USPSTF, 2018) [Class B] recommends screening

for osteoporosis in women age 65 years and older, and in women younger than age 65 years who have been through menopause and are at increased risk for osteoporosis (National Institute on Aging [NIA], 2017).

Plan

  1. Hypertension (HTN): controlled with Amlodipine and HCTZ, refill and continue, repeat lab work in 30
  2. Hyperlipidemia: controlled with Atorvastatin, continue, repeat Liver Profile in 30 days
  3. Osteoporosis: continue Alendronate, order Bone Density Test, add Ibuprofen 600mg PO q6h PRN for pain, repeat lab work in 30 days for CBC, CMP, TSH, calcium, B12, and Vitamin D (Kennedy-Malone,
  4. Dementia, moderate, possible Alzheimer’s disease: Add Donepezil (Aricept) tablet: initial dose of 5mg PO once Dose may be increased to 10 mg PO daily after 4-6 weeks if well tolerated; then increase to 23 mg PO daily after three months (National Institute on Aging, 2017).

The American Geriatrics Society (AGS) Beers Criteria for Potentially Inappropriate Medication (PIM) Use in Older Adults is an explicit list of PIMs best avoided in older adults in general and in those with certain diseases or syndromes, prescribed at reduced dosage or with caution or carefully monitored. According to the AGS PIM, the newly prescribed medications of donepezil and ibuprofen are accepted medications for the elderly.

Reflection

This experience has given me the opportunity to apply critical thinking skills to properly recognize the cognitive changes of confusion, disorientation, impaired short-term memory, personality changes, psychiatric symptoms, and changes in daily functioning. The readings this week helped differentiate delirium, dementia and depression as well. I found the video presentations and links very interesting and great guides to arriving at a proper plan of care for this patient. I don’t imagine there’s anyone who doesn’t know someone affected by Alzheimer’s Disease.

My sister-in-law’s mother just passed away at 94 years of age. She was severely affected by that horrible disease and my own stepfather is affected as well. It’s so sad to see them slip away from us. I was especially interested in being introduced to the Beers Criteria for Potentially Inappropriate Medication. I can’t believe I haven’t come upon it before now. My primary nursing focus was in critical care and I guess it just didn’t come up for discussion. My focus now is in geriatrics and I will surely be using the Beers criteria in caring for my patients in the future.

Health Promotion and Disease Prevention

Health Promotion: patient advised to incorporate an exercise routine into her daily routine for at least 3-5 days per week (American Heart Association, 2017 NRNP 6540 Week 2 SOAP Note Paper). Patient is up to date on routine mammogram and colonoscopy, screening for breast cancer and colon cancer.

Immunizations are currently up to date with the Tdap booster today. Closely monitor for compliance going forward.

Disease Prevention:

Cancer Screening for Breast and Colon Cancer: Patient had a mammogram in 2017, and colonoscopy in 2010. Now due for colonoscopy and mammogram. Women age 55 and up should have a mammogram every one-two year; and, both men and women should both be screened for colon cancer every 10 years by colonoscopy or other available methods beginning at 50 years of age (American Cancer Society, 2017).

COVID-19 recommendations for social distancing, excellent hygiene, facial covering when out in public, and avoiding contact with ill or compromised individuals must be reinforced to both BW and her daughter.

References for NRNP 6540 Week 2 SOAP Note Paper

Also Read: NRNP 6540 Week 2 Assignment: Assessing, Diagnosing, and Treating Dementia, Delirium, and Depression