The Soap Note and Presentation - Essay Example

The patient reports tonsillitis approximately two years ago; previous surgeries include appendectomy in 1987 and hysterectomy in 2011, no ongoing medical issues, LMP was March 17, 2012. No current medications. The patient denies any allergies. The patient denies shortness of breath or the presence of abdominal pain (Making).

The patient is married with two children, 12 and 9. Does not work outside of the home through reports being active and close to family members in the area. No family history of cancer, paternal grandfather high blood pressure, a mother with a history of diabetes. No religious preferences. Patients ceased smoking cigarettes 6 years ago, though the husband continues to smoke in the home.

Objective: BP 114/72 P74 T 100.2 R 20-

Weight 146 lb.

Appearance slightly fatigued, dark appearance around eyes

Lungs clear to auscultation, no rails, wheezing, resonant to percussion. The neck is supple to touch, no lymphadenopathy, no bruits. Oropharynx pink and moist, no exudate or erythema (Sample…), no drainage in posterior pharynx (Hagen). Nares without swelling or redness, no drainage, eye’s clear. Skin warm, pink, mucous membranes moist. Rapid strep test reports negative.

Assessment: Upper respiratory infection

Nursing Care Plan: Antibiotics are ineffective in a viral infection which is likely the case here. Supportive care should be provided. Increase fluid intake, patient should take Tylenol or Motrin for aches and pain.

Use a humidifier to keep throat tissues moist (Sample-2).

Wash hands frequently; avoid sharing glasses or eating utensils without first washing.

Avoid cigarette smoke, which will irritate the throat lining further.

Nursing Theory and Application: Orem’s theory of self-care considers the patient as a responsible individual who shares a beneficial relationship with the nurse. In applying Orem’s theory the patient is found to have no intolerance to any particular activity, strength is normal and cognitive function is not reduced. The individual demonstrates a good understanding of direction and is able to respond appropriately to questions. The patient shows no neuromuscular or musculoskeletal impairment. The patient is in excellent physical health with no deficits in activities of daily living (Sample).

Health Promotion: Age-related health promotion activities include a breast exam and mammogram; the patient should be taught a good technique for self-exam and also referred for a mammogram. A cholesterol profile, a pelvic exam, and pap smear should also be recommended.

Family Life Stage: The patient is in middle adulthood, Erikson’s generativity versus stagnation.  Work is very important during this stage, relationships and goals may be changing as children are possibly leaving home. Relationships are primarily in the family, work, and community. The task of this stage is to perpetuate values and culture to children and family members.

Cultural Characteristics, Diversity, and Sensitivity: A culturally diverse consideration that I discovered about this patient is that they have a very large and extensive family from which to gather support. Another factor that was identified is the patient expressed some family financial concerns and is worried about being able to retire at some point.

Evaluation: The note I felt is accurate, to the point, and written in a professional manner.