Expanded SOAP Note Analysis - Case Study Example

Expanded SOAP L.S. 6/24/10 Time: 9:30 Age: 81 Sex: F IVE CC: Patient c/o chest congestion for 4 days and follow up on blood work. HPI: Patient states for the last 4 days she has been experiencing chest congestion with greenish-yellowish sputum. States that she has been running low grade fevers and has been taking Tylenol for it. Has not tried any over the counter medications. She also states that she has missed a week of her Coumadin due to not feeling well and forgetting to take it. Medications: Digioxin 0.125mg qd (afib), nifedipine XL 30mg qd (htn), atenolol 50mg qd (htn), loprazepam 0.5mg prn (anxiety), flonase as needed (allergies), aspirin 81mg qd (heart), Claritin 10mg qd (allergies), warfarin 7.5mg M & W, 10mg T, Th, Sat, Sun. Xopenex FHA prn (COPD). PMH Allergies: Allergies: Shellfish, Cardizem, Tetanus Medication Intolerances: Chronic Illnesses/Major traumas: COPD, HTN, Atrial fibrillation, CVA 2004 Hospitalizations/Surgeries Hospitalizations/Surgeries: Tubal ligation, hysterectomy Family History Mother had heart disease and father had diabetes. Sister with breast cancer Social History Retired factory worker. Patient does not drink or smoke. She lives with her husband who smokes. ROS General Patient does c/o fevers and fatigue. Denies any chills or weight gain. Cardiovascular Patient denies any chest pains, orthopnea, or edema. Skin Patient denies any rashes or lesions. Does c/o bruises on legs from bumping into things Respiratory Patient does c/o coughing and wheezes dyspnea at times. Eyes Patient denies any visual changes. Wears glasses only for reading. Gastrointestinal Patient denies any frequent urination, dysuria, or hematuria. Ears Patient c/o decreased hearing in right ear. No ringing in ears or discharge Genitourinary/Gynecological Patient denies any frequent urination, dysuria, or hematuria. Nose/Mouth/Throat Denies any sinus pressure, denies dysphasia, and does c/o sore throat. Musculoskeletal Breast Patient denies any discharge or tenderness. Neurological Patient denies any headaches, seizures, or weakness. Neurological Heme/Lymph/Endo Patient denies any anemia. Does have increase in bruising due to medications. Psychiatric Patient denies any depression or suicidal ideations. Patient c/o anxiety at times. Psychiatric OBJECTIVE Weight 142 BMI 25.9 Temp 98.6 BP 156/90 Height 5’2 1/2 ‘ Pulse 90 Resp 16, O2 93% RPA General Appearance 81 year old ill appearing female. Alert and oriented Skin Skin is pink, warm, and dry. Bruises on left arm and bilateral lower extremities. HEENT Head is normocephalic, atraumatic and without lesions; hair evenly distributed. Eyes: PERRLA. 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 erythematous and without exudate. Dental appliance intact. Cardiovascular Irregular rate. No clicks or murmurs heard. No edema. Respiratory Symmetric chest wall. Respirations regular and unlabored. Lungs sound coarse. Gastrointestinal Positive bowel sounds x 4. Abdomen soft and non-tender. Breast Breast exam deferred. Genitourinary Bladder is non-distended; no CVA tenderness. Musculoskeletal Patient moves all extremities. Walks with assistance of a cane. Neurological Speech clear. Psychiatric Alert and oriented x 3, answers questions appropriately. Lab Tests INR (results are present) INR 1.1 Special Tests Chest x-ray (await call from radiology). FINAL ASSESSMENT FINDINGS AND PLAN o URI o Atrial fibrillation o Patient education on new Coumadin dosing. Patient to take warfarin 10mg on M, F and 7.5mg on T,TH,Sat, Sun. Patient to have labs redrawn in 2 weeks. Importance stress to patient in regards to not skipping medications. o fever Chest x ray results called back to office patient has right lower lobe pneumonia. Placed on Ceftin 500mg bid x 7 days, Medrol dose pack #1 Differential diagnosis Cough Palpitations Weakness Nursing Diagnosis Ineffective airway clearance r/t decreased energy or fatigue. Activity intolerance r/t to imbalance between oxygen supply and demand. Evaluation of care/documentation With this SOAP note I feel like I retrieved all of the pertinent information from the patient. With the antibiotic treatment I always feel as if I want to start with Amox since that was always the medication of choice. I guess as APN we will have to start thinking about cost effectiveness and exactly what’s appropriate for the patient. The Warfarin piece was good practice to see how they adjust dosing and why. Atrial Fibrillation Pathophysiology and Causes Atrial fibrillation is caused by atrial fibrosis, and loss of atrial muscle mass in which the AV node is bombarded by multiple waveforms within the atria.The loss of the atria kick can lead to stasis of blood in the left atrium which predisposes to formation of embolic or thrombi (Dunphy & Winland-Brown, 2007). Frequency Atrial fibrillation is the most frequently diagnosed arrhythmia and affects 2.3 million people in US. The prevelance of AF increases with age, and as many as 9% of people older than 80 years of age are affected. Rationalale for Medications Medications refilled for the patient were the Warfarin 5mg and also 1mg. This medication was refilled this way because the patient is elderly and it would be easier for her to take the medication this way. Patient was reeducation about the importance of needed to take the Warfarin to prevent reoccurent strokes. Warfarin- is an anti embolitic that is used to prevent clots from occurring. This is usually the first line drug of choice. This patient has had a previous history of CVA’s and also atrial fibrillation which puts her in a higher risk. Although she is elderly she is at a higher risk for falls so monitor her blood work is a very important factor in this case and also making sure that she clearly understands the importance of this medication. References Dunphy, L. M., Winland-Brown, J.E., Porter, B. O., &Thomas, D.J. (2007). Primary Care: The art and science of advanced practice nursing (2nd ed). Philadelphia: F. A. Davis. Sparks, S. M., & Taylor, C.M., (2006). Nursing diagnosis reference manual. (5th ed). Pennsylvania: Springhouse. ----------------------------- Analysis: The patient in this instance is an 81 year old female and reports a history of chronic illness in some areas, i.e, atrial fibrillation and COPD, together with HTN and CVN 2004. She has sought treatment in this instance specifically for chest pain and congestion with low grade fevers and has forgotten to take her Coumadin for several days. The diagnosis being made takes into account the two chronic conditions patient suffers from, i.e, atrial fibrillation and COPD also adds cva and hypertension, which appear to be concurrent. The primary and most pressing instant symptoms appear to be chest pain and fatigue. Medication prescribed was warfarin in initial high doses, ceftin for the chest infection and Medrol to manage the concomitant symptoms of allergies. Rationale for the management plan: As Dunphy and Winland-Brown (2007) have pointed out, atrial fibrillation is caused by the loss of atrial muscle mass where the AV node is bombarded by multiple waveforms, causing stasis of blood in the left atrium and predisposing to thrombosis. The patient had stopped taking Coumadin which partially explains the fluctuations in INR, with the present value being at 1.1, or a dangerously low level; however, rather than reverting back to Coumadin, Warfarin has been suggested because Coumadin is substantially more expensive for the customer, even with insurance picking up a major share of the tab. Since the patient appears to be in fair health otherwise, it appeared worthwhile to substitute a lower priced drug to achieve a concomitant result, since there is no substantial difference between Warfarin and Coumadin.In this case, the patient’s failure to take Coumadin. The treatment of the incipient chest infection cannot fail to take into account the patient’s existing condition of thrombosis, for which Warfarin was indicated. Since INR was below 1.5, initially higher doses of warfarin were prescribed, i.e, 10 mg on two days of the week. On the assumption that this would produce an increase in INR to about 1.8 to 1.9, the patient was advised to check back in two weeks time so that the INR could be checked again (www.med.umich.edu). The intervening doses on Tuesday, Thursday, Saturday and Sunday were adjusted down to 7.5mg and the treatment course aims to bring the patient INR to a target value of about 2.5, which is considered optimum in the case of arterial thrombosis, as is the case with this patient (www.gpnotebook.co.uk). The refill dosages suggested were 5mg and 1mg, because these were easier for the patient to take. Taking Coumadin would have required the patient to avoid eating vegetables entirely, hence Warfarin was a viable alternative. The dosages had to however be carefully chosen, because of the attendant complications as further detailed below. This was also one of the reasons why the refill dosages were kept small, so that the patient was not required to take higher doses without supervision; yet alternating a 5mg dose with a 1mg dose ensured that should the patient forget a dose, it could be compensated by the next one as far as possible. My natural inclination was to choose amoxicillin for the infection, which is often the antibiotic of choice. As Davydov (2003) found however, the administration of Warfarin and amoxicillin concurrently could cause a drug interaction which, with a rise in INR also produced bleeding complications. Although Davydov (2003) concludes that the exact cause for this remains unknown, it is possible that a decrease in the production of Vitamin K gut flora could produce a related Vitamin K deficiency, which produces the adverse effect of complications in bleeding. Since Warfarin itself could cause severe bleeding in some instances and the patient also shows increase in bruising which appears to be the result of medications, the potential complication of using amoxicillin and causing bleeding complications had to be taken into account. As a result, Ceftin was prescribed instead, at 500mg for 7 days, because it is a cephalosporin antibiotic which can be used for most bacterial infections, while Medrol was prescribed to manage the concomitant allergic symptoms because it did nor interact negatively with the other drugs. Integration of personal practice framework: In selecting the treatment plan, it was necessary to take into account, the cultural elements that could play a role in ensuring optimum results. According to Leininger, health care practitioners should fully discover the meanings, patterns and processes of care within the content of the cultural background of the patient, because this would not only help to explain what kind of care would be the best to promote the health of the patient but would also be the best predictor of health of the person (Leininger, 1998).The patient in this instance is an 81 year old white woman who was a factory worker. She is also independent and does not readily admit to weakness or frailty or the other symptoms of old age, although her hearing appears to be failing and she shows bruises from bumping into things. She demonstrates typical Western characteristics of endurance with a stiff upper lip; hence the treatment plan had to allow her to continue to exercise her own independence rather than making her feel that she was old and doddery and incapable. The importance of not missing out medication was underlined to her, but the practitioner took into account the fact that the high price of the drug could have been an inhibiting factor; hence quietly substituting Warfarin for Comadin allowed the patient to procure her medication at a lower price and was therefore likely to be more successful. Costs analysis: In terms of costs, it may be noted that the existing treatment plan provides a more cost effective option for the client. Since the patient requires a regular anti coagulant, the substitution of comadin with Warfarn allows the same condition to be addressed using a lower costing drug which is almost as good as the original. Moreover, the refill doses prescribed vary in their strength; as a result one expensive dose would be followed by a less expensive one. This reduces the overall costs of health care for this patient, since her advanced age means that she requires a substantial package of medication. Ethical considerations: In prescribing the course of treatment, the practitioner had to take into account the fact that the patient was a potential candidate for full time care; however when the patient demonstrates an independence and desire to live with her husband despite his smoking, mandating such a course could have infringed her autonomy. Hence the practitioner had to restrict the care and treatment given to the patient only to such areas as could safely be managed without such infringement. References: “Anti-coagulation management service for health professionals”, retrieved July 19, 2010 from: http://www.med.umich.edu/cvc/prof/anticoag/dose.htm Davydov, Liya, 2003. “Warfarin and Amoxycillin/Clavulanate drug interaction”, The annals of pharmacotherapy, 37(3): 367-370 Dunphy, L. M., Winland-Brown, J. E., Porter, B. O., & Thomas, D. J, 2007. “Primary care: The art and science of advanced practice nursing”, Philadelphia: F. A. Davis Company. Leininger, Madeleine M, 1998. “Leininger’s Theory of Nursing: Cultural care diversity and universality”, Nursing Science Quarterly, 1:152-160 “Warfarin:INR ranges and length of treatment in various conditions”, retrieved July 20, 2010 from: http://www.gpnotebook.co.uk/simplepage.cfm?ID=1617625155 Read More