Soap Note Acute Care NP

Home>Homework Answsers>Nursing homework helpplease elaborate a soap note at a master’s level for acute care following the attached format2 years ago25.11.202310Report issuefiles (1)ICUSOAPExample.pdfICUSOAPExample.pdfAGACNP ICU SOAP Note EXAMPLEAGAC StudentMM/DD/YYNURS XX Week 7 SOAP NoteLevel of Care: ICUHospital Day: 2Specialty: IntensivistDemographic Data : S.J. 42 year old Black femaleSUBJECTIVE
Chief Complaint (CC): Nods head when asked if experiencing abd pain – Unable toverbalize/IntubatedHistory of Present Illness (HPI) : Reviewing the chart, patient presented yesterday from hometo ER with 1 day of severe, sharp, constant pelvic abd pain after 4 days of nausea, vomiting anddiarrhea. Denied fever or chills. Reported stool was loose, brown, and watery with no foul smell.Abd pain was in the lower pelvis, worse with walking or urination, better with lying down. Notimproved with OTC ibuprofen. Denied urinary symptoms of pain, frequency or blood in urine.Denied vaginal symptoms or discharge. When asked today if pain is better – patient shakes herhead “No”. Nods her head “Yes” that the morphine does improve symptoms.Current Home Medications Only: Ibuprofen OTCAllergies: NKDAPast Medical History: DeniesPast Surgical History: C-section 5 years agoSocial History: Patient lives at home with her spouse. He is supportive. She works full time as abank manager. Unable to obtain further data at this time due to inability to verbalize.Family History: On the chart – lists mother alive at 72 in excellent health, and father alive at 70with HTN.Immunization History: Unable to obtain.Preventative Health History: Unable to obtainREVIEW OF SYSTEMS – Unable to obtain due to patient intubated.General: Eyes: Ears, nose, mouth &throat: Cardiovascular: Respiratory: Gastrointestinal: Skin & Breasts:Musculoskeletal: Allergic: Immunologic: Endocrine: Hematopoietic/Lymphatic:Genitourinary: Neurological: Psychiatric/Mental Status:OBJECTIVE
Vital Signs: 90/55, HR 125 Normal Sinus Tach, RR 26, FiO2 30% on AC Vent PS 5 PEEP5,VT 500 – SpO2 93%Laboratory Values: WBC 23.4K, Hgb 8.2, Hct 24.5, Plt 70K; Glu 70, BUN 20, Cr 1.9, K 3.0,Na 135. Lactate 4.8, ABG: pH 7.35, PaO2 85%, PCO2 30Radiology Results: CT scan abd/pelvis with IV contrast – ruptured appendicitis with abscess.CXR – no PNA, no pleural effusion, ETT in good position, Central line good position.I&O values: UO 20cc/hr, total 500cc/24 hours, IVF 5000 in 24 hours. No BM.Focused Inpatient Medications: Zosyn 3.375gm IV Q6H, Pepcid 20mg IV Q12H, Heparin5000U SQ Q8H, Propofol per protocol. Morphine 4 mg IV Q2H PRN Pain. Levophed gtt at 5mcg/min. D5 ½ with 20mEq Kcl @ 125cc/hr.Nurse/Consultant Note Review: Patient was intubated yesterday when her sepsis progressed tosignificant hypotension, severe metabolic acidosis, and she developed ALOC with concern tomaintain own airway. General Surgery Consult – Ruptured appendicitis, plan for IR drainage,non-op management unless overwhelming sepsis or acute abd. IR Consult – Plan for IR drainagepelvic abscess today. Per RN/RT – patient tolerating weaning trial, ABG normalizing, improvedBP, weaning pressors.PHYSICAL EXAMGeneral: Well developed, well nourished female, appropriate to stated age. ETT/Vent. Leftsubclavian central line.Eyes: EOM intact. Excellent eye contact. Atraumatic eyelids/sclera. PERRLAEars, nose, mouth & throat: Ears/nose/mouth – grossly intact. Oral mucosa moist. Throat -deferred due to intubation.Cardiovascular: NST on tele. Heart S1S2, RRR, no murmurs, no rubs. No peripheral edema.Bilateral radial/dorsalis pedis +3 pulses. Warm, dry extremities. Cap Refill briskRespiratory: Lungs clear bilaterally. Chest expansion bilaterally.Gastrointestinal: Abd soft, distended, tenderness to palpation and guarding over pelvis/RLQ.Non-tender upper quadrants. Hypoactive bowel sounds.Skin & Breasts: Skin grossly intact/pink warm. Breasts deferred.Musculoskeletal: Grossly moves all extremities spontaneously in bed. Purposefully uses armsto adjust gown. Follows commands.Allergic: DeferredImmunologic: DeferredEndocrine: DeferredHematopoietic/Lymphatic: No lymphadenopathy of cervical, clavicular chains. No inguinallymphadenopathy. No bruising noted.Genitourinary: Foley – amber urineNeurological: Alert. Nods head appropriately. Will evaluate CN 2-12 after extubation. Equalgrips 5/5, equal dorsiflex/plantarflex 5/5.Psychiatric/Mental Status: Appropriate. No noted distress.ASSESSMENT
Differential Diagnosis (DDx):While the patient is experiencing Sepsis, AKI, and Respiratory failure – this is a ProblemFocused SOAP note – and I will focus on the Abdominal differentials/final diagnoses as theabdomen is the source of the Sepsis, AKI, and Respiratory Failure.Perforated colonic diverticulitis ICD 10 K57.20Colonic diverticulosis is an outpouching of the colon wall. When this becomes irritated, inflamedor obstructed -it can progress to diverticulitis. This can be complicated or uncomplicated. Thediverticulitis can spontaneously resolve without treatment or can progress to perforation and/orabscess. Most patients will present with abdominal pain and change in bowel habits, andsometimes fever. Routine care can include outpatient monitoring by PCP, change of diet and/orantibiotics. When the patient experiences perforation, abscess or signs of sepsis, hospitaladmission is required. CT scan of the abdomen/pelvis with IV contrast is the standard forradiology evaluation for diagnosis, PO contrast can be included if able. CBC can be obtained toassist in evaluation of both in-patient and out-patient for leukocytosis. The patient will requirealteration in diet or NPO status, GI and/or surgery consultation, antibiotics, and/or painmanagement. Cancer can sometimes be the cause of diverticulosis to progress to diverticulitis,and the patient should have an out-patient screening colonoscopy when diverticulitis hasresolved. Pertinent positives: leukocytosis, tachycardia, abdominal pain, fever, CT scan – abscessnear colon, patient age of 40’s, diarrhea. Pertinent negatives: CT scan read of rupturedappendicitisCrohn’s Disease K 50.90Crohn’s Disease is an autoimmune disease of the intestines which can affect the colon. Crohn’sdisease can present with chronic symptoms of diarrhea, abdominal pain and/or blood in stool.Crohn’s patient can have swelling and inflammation of the bowels, which can result in scarringand strictures of the bowel. Crohn’s patients can also have perforation of the bowels due toinflammation and swelling. Patients presenting with abdominal pain, and possible Crohn’sshould have routine labs sent (CBC/BMP) and a CT scan of abd/pelvis with IV contrast, POcontrast if able. If Crohn’s is suspected, GI should be consulted. If perforation, the patient willrequire antibiotics. If a patient with Crohn’s has perforation or stricture, specialized surgicalconsult should be obtained, Colorectal if possible. Definitive diagnosis is with pathology fromGI biopsy or surgical sample. Pertinent positives: Anemia, fever, tachycardia, hypotension,diarrhea, abdominal pain, CT scan read of abscess in pelvis. Pertinent negatives: No hx ofchronic GI symptoms, no noted thickening of bowel walls on CT scan.Final Diagnosis:Ruptured appendicitis with intra-abd abscess K 35.33The appendix is an organ that comes off of the base cecum. When it becomes inflamed orobstructed, it can rupture, allowing enteric bacteria into the sterile peritoneal cavity. Someuncomplicated appendicitis can resolve without treatment. Appendicitis is typically diagnosed bycomplaints of 1-2 days of abd pain, possible fever, typically negative for nausea, vomiting,diarrhea. Appendicitis can be diagnosed on abd exam: RLQ pain to palpation, peritonitis (LLQrebound tenderness – Rovsing’s sign). Elevated WBC on CBC. If avoiding radiation in childrenor pregnant women, US or MRI can be ordered. Standard diagnosis involves CT scan Abd/pelviswith IV contrast. Appendicitis can be treated with IV and/or PO antibiotics if uncomplicated,with the understanding that the patient has higher risk for recurrent appendicitis in future.Appendicitis can be treated with appendectomy, typically laparoscopic. With rupturedappendicitis with abscess, there is significant inflammation in the peritoneal cavity – and IRdrain of abscess, culture of fluid, and appropriate antibiotics is the primary treatment, withinterval Appendectomy as an out-patient when the patient has recovered. If the patient failsantibiotic/IR management, they can require an appendectomy in-patient and this has increasedrisk of requiring an open procedure, requiring an ileocecectomy, post-op intra-abdominalabscess, intra-op injury to ureters, etc. If the patient is female, TOA, PID, ovarian cyst, andovarian torsion could be considered in the differentials.PLAN
Treatment (Tx) Plan:1. Acute ruptured appendicitis with abscess: As per Surgery/IR – will plan for IR perc drainof intra-abd abscess. Send fluid for culture. Continue Zosyn as ordered for 10 days ofantibiotic therapy. Leukocytosis improving, lactate improving, Pressors continued forhypotension, low UO with AKI. Fluid resuscitation.2. Resp Failure – ABG WNL today. Wean vent to extubation, O2 per protocol. Pulmonarytoilet IS, cough and deep breathe Q1H while awake.3. AKI: IVF resuscitation to improve UO, BP, and Creatinine, goal wean Levophed off andmaintain SBP >90: 1000cc bolus NS now, strict I&O, continue foley.4. Nutrition: NPO until cleared by Surgery, continue stress ulcer prophylaxis.5. DVT prophylaxis: continue heparin SQ/SCD, begin OOB activity, PT/OT eval and treat.6. Labs: Replace Hypokalemia – 40Meq KCl over 4 hours IV and recheck Serum K in 4hours. Recheck anemia, thrombocytopenia and AKI in am: CBC, Basic Metabolic Panel.Patient seen and evaluated with Dr. Hardin.Patient Education: Educate patient on ruptured appendicitis: plan for antibiotics and IR drain.Plan to advance patient activity, resume PO intake when cleared by surgery. If bowel functionreturns and abdominal exam is non-tender – will transfer to MedSurg and plan to go home andsee Surgery Out-patient. Discharge may include drain and antibiotics. If labs, vitals, bowelfunction and abdominal exam do not improve to normal- patient may be re-evaluated for surgerythis admission.Prognosis Good, Fair, or Poor: GoodReferral/Follow-up: Outpatient primary care due to AKI. Outpatient surgery clinic for Intervalappendectomy when abscess is resolved. If patient goes home with drain – will need to follow upat IR clinic.Disposition: Goal to progress to MedSurg in 1-2 days, plan for d/c home < 7 days. If patient hasdrain at home, consider home health referral.Reference(s):www.iknowalot.comm – Use appropriate APAwww.allthehealthinfo.comm – Use appropriate APAwww.betterthangoogle.comm – Use appropriate APAhttp://www.iknowalot.comm/http://www.allthehealthinfo.comm/http://www.betterthangoogle.comm/APPENDIX APREVENTATIVE CARE SCHEDULE (Example – not all-inclusive)Preventive Care Date Result Referrals MadePapMammogramA1CEye ExamMonofilamentTestUrineMicroalbuminDiet/LifestyleModificationsDigital RectalExam (DRE)PSAColonoscopy orFOBTDexa ScanCXRBNPECGEchoStressTestVaccinesICUSOAPExample.pdfAGACNP ICU SOAP Note EXAMPLEAGAC StudentMM/DD/YYNURS XX Week 7 SOAP NoteLevel of Care: ICUHospital Day: 2Specialty: IntensivistDemographic Data : S.J. 42 year old Black femaleSUBJECTIVE Chief Complaint (CC): Nods head when asked if experiencing abd pain – Unable toverbalize/IntubatedHistory of Present Illness (HPI) : Reviewing the chart, patient presented yesterday from hometo ER with 1 day of severe, sharp, constant pelvic abd pain after 4 days of nausea, vomiting anddiarrhea. Denied fever or chills. Reported stool was loose, brown, and watery with no foul smell.Abd pain was in the lower pelvis, worse with walking or urination, better with lying down. Notimproved with OTC ibuprofen. Denied urinary symptoms of pain, frequency or blood in urine.Denied vaginal symptoms or discharge. When asked today if pain is better – patient shakes herhead “No”. Nods her head “Yes” that the morphine does improve symptoms.Current Home Medications Only: Ibuprofen OTCAllergies: NKDAPast Medical History: DeniesPast Surgical History: C-section 5 years agoSocial History: Patient lives at home with her spouse. He is supportive. She works full time as abank manager. Unable to obtain further data at this time due to inability to verbalize.Family History: On the chart – lists mother alive at 72 in excellent health, and father alive at 70with HTN.Immunization History: Unable to obtain.Preventative Health History: Unable to obtainREVIEW OF SYSTEMS – Unable to obtain due to patient intubated.General: Eyes: Ears, nose, mouth &throat: Cardiovascular: Respiratory: Gastrointestinal: Skin & Breasts:Musculoskeletal: Allergic: Immunologic: Endocrine: Hematopoietic/Lymphatic:Genitourinary: Neurological: Psychiatric/Mental Status:OBJECTIVE Vital Signs: 90/55, HR 125 Normal Sinus Tach, RR 26, FiO2 30% on AC Vent PS 5 PEEP5,VT 500 – SpO2 93%Laboratory Values: WBC 23.4K, Hgb 8.2, Hct 24.5, Plt 70K; Glu 70, BUN 20, Cr 1.9, K 3.0,Na 135. Lactate 4.8, ABG: pH 7.35, PaO2 85%, PCO2 30Radiology Results: CT scan abd/pelvis with IV contrast – ruptured appendicitis with abscess.CXR – no PNA, no pleural effusion, ETT in good position, Central line good position.I&O values: UO 20cc/hr, total 500cc/24 hours, IVF 5000 in 24 hours. No BM.Focused Inpatient Medications: Zosyn 3.375gm IV Q6H, Pepcid 20mg IV Q12H, Heparin5000U SQ Q8H, Propofol per protocol. Morphine 4 mg IV Q2H PRN Pain. Levophed gtt at 5mcg/min. D5 ½ with 20mEq Kcl @ 125cc/hr.Nurse/Consultant Note Review: Patient was intubated yesterday when her sepsis progressed tosignificant hypotension, severe metabolic acidosis, and she developed ALOC with concern tomaintain own airway. General Surgery Consult – Ruptured appendicitis, plan for IR drainage,non-op management unless overwhelming sepsis or acute abd. IR Consult – Plan for IR drainagepelvic abscess today. Per RN/RT – patient tolerating weaning trial, ABG normalizing, improvedBP, weaning pressors.PHYSICAL EXAMGeneral: Well developed, well nourished female, appropriate to stated age. ETT/Vent. Leftsubclavian central line.Eyes: EOM intact. Excellent eye contact. Atraumatic eyelids/sclera. PERRLAEars, nose, mouth & throat: Ears/nose/mouth – grossly intact. Oral mucosa moist. Throat -deferred due to intubation.Cardiovascular: NST on tele. Heart S1S2, RRR, no murmurs, no rubs. No peripheral edema.Bilateral radial/dorsalis pedis +3 pulses. Warm, dry extremities. Cap Refill briskRespiratory: Lungs clear bilaterally. Chest expansion bilaterally.Gastrointestinal: Abd soft, distended, tenderness to palpation and guarding over pelvis/RLQ.Non-tender upper quadrants. Hypoactive bowel sounds.Skin & Breasts: Skin grossly intact/pink warm. Breasts deferred.Musculoskeletal: Grossly moves all extremities spontaneously in bed. Purposefully uses armsto adjust gown. Follows commands.Allergic: DeferredImmunologic: DeferredEndocrine: DeferredHematopoietic/Lymphatic: No lymphadenopathy of cervical, clavicular chains. No inguinallymphadenopathy. No bruising noted.Genitourinary: Foley – amber urineNeurological: Alert. Nods head appropriately. Will evaluate CN 2-12 after extubation. Equalgrips 5/5, equal dorsiflex/plantarflex 5/5.Psychiatric/Mental Status: Appropriate. No noted distress.ASSESSMENT Differential Diagnosis (DDx):While the patient is experiencing Sepsis, AKI, and Respiratory failure – this is a ProblemFocused SOAP note – and I will focus on the Abdominal differentials/final diagnoses as theabdomen is the source of the Sepsis, AKI, and Respiratory Failure.Perforated colonic diverticulitis ICD 10 K57.20Colonic diverticulosis is an outpouching of the colon wall. When this becomes irritated, inflamedor obstructed -it can progress to diverticulitis. This can be complicated or uncomplicated. Thediverticulitis can spontaneously resolve without treatment or can progress to perforation and/orabscess. Most patients will present with abdominal pain and change in bowel habits, andsometimes fever. Routine care can include outpatient monitoring by PCP, change of diet and/orantibiotics. When the patient experiences perforation, abscess or signs of sepsis, hospitaladmission is required. CT scan of the abdomen/pelvis with IV contrast is the standard forradiology evaluation for diagnosis, PO contrast can be included if able. CBC can be obtained toassist in evaluation of both in-patient and out-patient for leukocytosis. The patient will requirealteration in diet or NPO status, GI and/or surgery consultation, antibiotics, and/or painmanagement. Cancer can sometimes be the cause of diverticulosis to progress to diverticulitis,and the patient should have an out-patient screening colonoscopy when diverticulitis hasresolved. Pertinent positives: leukocytosis, tachycardia, abdominal pain, fever, CT scan – abscessnear colon, patient age of 40’s, diarrhea. Pertinent negatives: CT scan read of rupturedappendicitisCrohn’s Disease K 50.90Crohn’s Disease is an autoimmune disease of the intestines which can affect the colon. Crohn’sdisease can present with chronic symptoms of diarrhea, abdominal pain and/or blood in stool.Crohn’s patient can have swelling and inflammation of the bowels, which can result in scarringand strictures of the bowel. Crohn’s patients can also have perforation of the bowels due toinflammation and swelling. Patients presenting with abdominal pain, and possible Crohn’sshould have routine labs sent (CBC/BMP) and a CT scan of abd/pelvis with IV contrast, POcontrast if able. If Crohn’s is suspected, GI should be consulted. If perforation, the patient willrequire antibiotics. If a patient with Crohn’s has perforation or stricture, specialized surgicalconsult should be obtained, Colorectal if possible. Definitive diagnosis is with pathology fromGI biopsy or surgical sample. Pertinent positives: Anemia, fever, tachycardia, hypotension,diarrhea, abdominal pain, CT scan read of abscess in pelvis. Pertinent negatives: No hx ofchronic GI symptoms, no noted thickening of bowel walls on CT scan.Final Diagnosis:Ruptured appendicitis with intra-abd abscess K 35.33The appendix is an organ that comes off of the base cecum. When it becomes inflamed orobstructed, it can rupture, allowing enteric bacteria into the sterile peritoneal cavity. Someuncomplicated appendicitis can resolve without treatment. Appendicitis is typically diagnosed bycomplaints of 1-2 days of abd pain, possible fever, typically negative for nausea, vomiting,diarrhea. Appendicitis can be diagnosed on abd exam: RLQ pain to palpation, peritonitis (LLQrebound tenderness – Rovsing’s sign). Elevated WBC on CBC. If avoiding radiation in childrenor pregnant women, US or MRI can be ordered. Standard diagnosis involves CT scan Abd/pelviswith IV contrast. Appendicitis can be treated with IV and/or PO antibiotics if uncomplicated,with the understanding that the patient has higher risk for recurrent appendicitis in future.Appendicitis can be treated with appendectomy, typically laparoscopic. With rupturedappendicitis with abscess, there is significant inflammation in the peritoneal cavity – and IRdrain of abscess, culture of fluid, and appropriate antibiotics is the primary treatment, withinterval Appendectomy as an out-patient when the patient has recovered. If the patient failsantibiotic/IR management, they can require an appendectomy in-patient and this has increasedrisk of requiring an open procedure, requiring an ileocecectomy, post-op intra-abdominalabscess, intra-op injury to ureters, etc. If the patient is female, TOA, PID, ovarian cyst, andovarian torsion could be considered in the differentials.PLAN Treatment (Tx) Plan:1. Acute ruptured appendicitis with abscess: As per Surgery/IR – will plan for IR perc drainof intra-abd abscess. Send fluid for culture. Continue Zosyn as ordered for 10 days ofantibiotic therapy. Leukocytosis improving, lactate improving, Pressors continued forhypotension, low UO with AKI. Fluid resuscitation.2. Resp Failure – ABG WNL today. Wean vent to extubation, O2 per protocol. Pulmonarytoilet IS, cough and deep breathe Q1H while awake.3. AKI: IVF resuscitation to improve UO, BP, and Creatinine, goal wean Levophed off andmaintain SBP >90: 1000cc bolus NS now, strict I&O, continue foley.4. Nutrition: NPO until cleared by Surgery, continue stress ulcer prophylaxis.5. DVT prophylaxis: continue heparin SQ/SCD, begin OOB activity, PT/OT eval and treat.6. Labs: Replace Hypokalemia – 40Meq KCl over 4 hours IV and recheck Serum K in 4hours. Recheck anemia, thrombocytopenia and AKI in am: CBC, Basic Metabolic Panel.Patient seen and evaluated with Dr. Hardin.Patient Education: Educate patient on ruptured appendicitis: plan for antibiotics and IR drain.Plan to advance patient activity, resume PO intake when cleared by surgery. If bowel functionreturns and abdominal exam is non-tender – will transfer to MedSurg and plan to go home andsee Surgery Out-patient. Discharge may include drain and antibiotics. If labs, vitals, bowelfunction and abdominal exam do not improve to normal- patient may be re-evaluated for surgerythis admission.Prognosis Good, Fair, or Poor: GoodReferral/Follow-up: Outpatient primary care due to AKI. Outpatient surgery clinic for Intervalappendectomy when abscess is resolved. If patient goes home with drain – will need to follow upat IR clinic.Disposition: Goal to progress to MedSurg in 1-2 days, plan for d/c home < 7 days. If patient hasdrain at home, consider home health referral.Reference(s):www.iknowalot.comm – Use appropriate APAwww.allthehealthinfo.comm – Use appropriate APAwww.betterthangoogle.comm – Use appropriate APAhttp://www.iknowalot.comm/http://www.allthehealthinfo.comm/http://www.betterthangoogle.comm/APPENDIX APREVENTATIVE CARE SCHEDULE (Example – not all-inclusive)Preventive Care Date Result Referrals MadePapMammogramA1CEye ExamMonofilamentTestUrineMicroalbuminDiet/LifestyleModificationsDigital RectalExam (DRE)PSAColonoscopy orFOBTDexa ScanCXRBNPECGEchoStressTestVaccinesBids(72)Miss DeannaDr. Ellen RMnicohwilliamPROF_ALISTEREmily ClareSheryl HoganDr. Freya WalkerDoctor.Namirafirstclass tutorProf Double RDemi_RoseFiona DavaIsabella HarvardMUSYOKIONES A+Dr CloverMISS HILLARY A+Discount AssignJudithTutorSTELLAR GEEK A+Jahky BShow All Bidsother Questions(10)qdiscussionShort EssayIA#2Order 800397: academic skillsOrder 778593: Policy Analysis of Don′t Ask Don′t Tellweek5finance unit 7Discussion due 2/29/2020, Do not put in bid if you can not completer by due dateOrder 546087: Are there vocal cues to human developmental stability? Relationships between facial fluctuating asymmetry and voice attractiveness.

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