Archive for category: Timely Nursing Papers

Case Study 1 Headaches: Neurological system and continue practicing documentation of a focused/episodic SOAP note for Assignment 

A 20-year-old male complains of experiencing intermittent headaches. The headaches diffuse all over the head, but the greatest intensity and pressure occurs above the eyes and spreads through the nose, cheekbones, and jaw.

Episodic/Focused SOAP Note Template

Patient Information:

Initials, Age, Sex, Race

S.

CC (chief complaint) a BRIEF statement identifying why the patient is here – in the patient’s own words – for instance, “headache”, NOT “bad headache for 3 days”.

HPI: This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. Use LOCATES Mnemonic to complete your HPI. You need to start EVERY HPI with age, race, and gender (e.g., 34-year-old AA male). You must include the seven attributes of each principal symptom in paragraph form, not a list. If the CC was “headache”, the LOCATES for the HPI might look like the following example:

Location: head

Onset: 3 days ago

Character: pounding, pressure around the eyes and temples

Associated signs and symptoms: nausea, vomiting, photophobia, phonophobia

Timing: after being on the computer all day at work

Exacerbating/ relieving factors: light bothers eyes, Aleve makes it tolerable but not completely better

Severity: 7/10 pain scale

Current Medications: include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.

Allergies: include medication, food, and environmental allergies separately (a description of what the allergy is ie angioedema, anaphylaxis, etc. This will help determine a true reaction vs intolerance).

PMHx: include immunization status (note date of last tetanus for all adults), past major illnesses and surgeries. Depending on the CC, more info is sometimes needed
Soc Hx: include occupation and major hobbies, family status, tobacco & alcohol use (previous and current use), any other pertinent data. Always add some health promo question here – such as whether they use seat belts all the time or whether they have working smoke detectors in the house, living environment, text/cell phone use while driving, and support system.

Fam Hx: illnesses with possible genetic predisposition, contagious or chronic illnesses. The reason for the death of any deceased first degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent.

ROS: cover all body systems that may help you include or rule out a differential diagnosis You should list each system as follows: General: Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe.

Example of Complete ROS:

GENERAL:  No weight loss, fever, chills, weakness or fatigue.

HEENT:  Eyes:  No visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat:  No hearing loss, sneezing, congestion, runny nose or sore throat.

SKIN:  No rash or itching.

CARDIOVASCULAR:  No chest pain, chest pressure or chest discomfort. No palpitations or edema.

RESPIRATORY:  No shortness of breath, cough or sputum.

GASTROINTESTINAL:  No anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.

GENITOURINARY:  Burning on urination. Pregnancy. Last menstrual period, MM/DD/YYYY.

NEUROLOGICAL:  No headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.

MUSCULOSKELETAL:  No muscle, back pain, joint pain or stiffness.

HEMATOLOGIC:  No anemia, bleeding or bruising.

LYMPHATICS:  No enlarged nodes. No history of splenectomy.

PSYCHIATRIC:  No history of depression or anxiety.

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

ALLERGIES:  No history of asthma, hives, eczema or rhinitis.

O.

Physical exam: From head-to-toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History. Do not use “WNL” or “normal.” You must describe what you see. Always document in head to toe format i.e. General: Head: EENT: etc.

Diagnostic results: Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines)

A.

Differential Diagnoses (list a minimum of 3 differential diagnoses).Your primary or presumptive diagnosis should be at the top of the list. For each diagnosis, provide supportive documentation with evidence-based guidelines.

APA citation 4 to 5 Reference with 5 years.

Research health care legislation that is being considered in your state. What impact might this legislation have on your future practice? What impact does it have on the collective practice of nurses in your state? How do you envision yourself potentially becoming involved in political advocacy for the profession in your future practice?

Acute Asthma

Mr. Jefferson who is aged 30 years old walks into your clinic. You already are aware that he has asthma since this is not his first time at the clinic. He goes no to inform you clearly that in the last two or three weeks, he has had sleepless nights and is constantly awakened by coughs. Due to this intensified coughing, he has had to increase the use of his salbutamol inhaler every day.  His peak flow has also increased especially in the morning and at night. Mr. Jefferson has also been transferred at work and he now operates mostly in the open which could be an exposure to allergens or cold weather.

Psychophysiology of Asthma Following Exposure to Cold weather

In a case of acute asthma, the exacerbation comes about due to the contraction or else the bronchoconstriction of the smooth muscles of the bronchiole. When this happens, the airways are narrowed in a response to certain agents. These agents are stimuli and are either irritants or allergens (VanMeter and Hubert 2014). The exposure to these stimuli triggers allergies in the system of a patient and hence portraying the symptoms and signs of an asthma attack.

Early Signs of Acute Asthma Attack

Being a chronic illness, the effect of asthma on a patient’s body are long-lasting and hence it makes the control of the disease a process. The infection affects the airways and also the lungs. The airways become narrowed and inflamed occasionally. The patient then experiences wheezing due to bronchoconstriction. There is also the production of thick mucus which in turn causes coughing and leads to improper breathing. The short breaths are brought about by poor oxygen supply. There is also tightening of the chest. All these are signs that Mr. Jefferson has experienced.

Significant Medical and Drug History Questions

As a medical personnel, it is important to know exactly the record of the patient you are dealing with since the onset of the asthmatic attacks to his current state. This will enable you to plan, updates and also to provide the best medical advice possible to the patient. You should ask questions such as; if he has commenced on any medication?  Is there any medication that he has stopped since the last meeting? Has he noted any new allergic responses since the last meeting? When was the last asthma attack and how long did it last? What his feeding habits? The medical history of his family and whether they have a history of asthma attacks? And many more relevant questions that will help you get the right medication for the patient.

Precautions in Treatment

The most important factor that one is to consider while providing the appropriate medication for any asthma patient, is to provide a process that will reduce the severity of asthma attacks to prevent more damage on the patient’s respiratory organs (Sun 2017). The patient should also be given precautions to avoid things and activities that may trigger their asthma attacks. Items such as colognes, perfumes and smoking should be avoided at all costs. The patient in this case should also avoid going out into the cold while dressed inappropriately.  He should always protect his own health first by keeping warm and avoiding the cold.

Effects of Prolonged Asthma Attack

With more asthma attacks that are uncontrollable, the patient is at high risk of losing their life. This is due to conditions known as acidosis and hypoxia which may lead to other fatal conditions such cardiac arrhythmias (Tello et al 2019). These frequent attacks can be terminal and may weaken one for life until they succumb to the condition.

Measures to reduce Anxiety

The signs and symptoms of asthma can be frightening especially to young people. The inability to breath or breath well is a very scary ordeal that may lead to someone with acute asthma developing other conditions. It may lead to severe cases of anxiety that is further detrimental to the general health and well-being of a patient. The patient should therefore avoid factors that may trigger any asthma attacks.

Inhalers and Their Use in the Control of Acute Asthma

When you get to look at his PMH, it shows a maintenance of 2 puffs of salbutamol MDI and beclometasone 100 MDI also 2puffs a day. He has also been on antihistamines for a while. The immediate care protocol to ensure that he receives include; stopping his use of the beclometasone inhaler in order to reduce the inhalation of steroids and to explain that he needs to ensure that he is using his inhaler as prescribed and also following the set procedure such as cleaning his mouth and brushing after using the inhaler (VanMeter and Hubert 2014).

Likelihood of Frequent Respiratory Infections

A patient such as Mr. Jefferson who has asthma is at a very high risk of infection from other illnesses caused by mostly virus and bacteria (Doshi et al 2017). Their bodies are weakened and hence the risk of infection from these organisms is increased. Being a topic condition, asthma increases a patient’s susceptibility to both non-respiratory microbial and respiratory infections.

Dental Procedure Concerns

Medical reports and research has proven and shown that dental material may be a cause for further exacerbation in cases of acute asthma. These concerns include; tooth enamel dust, dentifrices, fissure sealants, fluoride trays and cotton rolls. One is, therefore advised to always have supplemental oxygen during the treating of an asthmatic patient just in case of an exacerbation.

Nutrition

Cases of acute asthma can be either increased or reduced by the different diets as taken by a patient. Patients who feed on food that is loaded with Vitamin C and E, magnesium, selenium and omega-3 fatty acids have a decreased rate of asthma attacks. Most of the nutritious value of these substances provide antioxidants which are very essential for the protection of cells and ensuring minimum damage. Asthmatic patients should also avoid cow’s milk, soy, wheat, eggs, tree nuts and fish (VanMeter and Hubert 2014).

Aspects of Immobility

Patients with acute asthma such as Mr. Jefferson just like any other with respiratory conditions develop an increased rate in their mobility with time as the exacerbations affect their ability to move with time. This is mainly due to weakened muscles due to less and less activity. Most of them are usually aged and hence their movement is highly reduced.

Respond with 8-9 sentences , 2 APA  Schorlay citataions

Influenza A

Mrs. A.H. had an acute episode of influenza A, complicated by pneumococcal pneumonia. She lives in a senior apartment building where a number of residents have had influenza in the past month.
Causes of influenza and its effects on the lungs
      Influenza is a caused by the influenza virus, and is highly contagious. There are three groups of the influenza virus; type A, B and C. Type A is the most prevalent of the three types. Influenza may affect both the upper and lower respiratory tract (Huber and VanMeter, 2018). The hemagglutinin (HA) molecule adheres to the respiratory epithelium and generates infectious virus particles. Transmission occurs when a susceptible host is exposed to virus particles through aerosol or other surfaces contaminated by an infected person. Influenza causes inflammation in the lungs, they become compromised secondary to the viral infection in the respiratory epithelium in conjunction with the inflammation caused by the immune response activated to fight off the infection (Kalil and Thomas, 2019).
The normal mechanism that defend against infection in the respiratory tract
The normal mechanism that that defend the lungs against infection is mucociliary clearance. In the respiratory mucosa the epithelium is covered with cilia and globlet cells that secrete mucous. This forms a thin layer of mucous, that traps pathogens and inhaled particles, while the cilia propel them up and out of the respiratory tract. A cough or sneeze is stimulated by excessive mucous or foreign particles in the respiratory tract resulting in further expulsion and prevention of entry into the lungs (Huber and VanMeter, 2018).
Susceptibility
      It can be expected that a number of residents in a senior apartment building would be affected by the influenza for a number of reasons. The first being that influenza virus is highly contagious. Also because of its incubation period which is 1-4 days, this means that the virus can be passed on one day before symptoms develop and for up to five days after (Hubert and VanMeter, 2018). These elderly residents have increased susceptibility as a result of their age, they are elderly usually over the age of 65 years; this age group is high risk. Additionally, resident in senior apartment building tend to participate in shared activities, they share facilities, and transportation.
Precautions to avoid being infected
      The single best way to for the residents to avoid being infected is by getting vaccinated against the influenza virus yearly. The residents will have to be vaccinated yearly against influenza because the influenza viruses are constantly mutating. As a result, effective immunity does not last for a long period of time (Hubert and VanMeter, 2018). Apart from being vaccinated the resident can follow some basic practices such as good hand hygiene, cover their noses and mouths when coughing or sneezing, skipping group activities if they are sick, avoid contact with other residents who are sick, drink plenty of fluids, eat plenty of fruits and vegetables especially those rich in vitamin C.
Precautions to reduce the risk of respiratory infections in the professional environment
      To reduce the risk of respiratory infection in the professional environment the single most important precaution would be to get vaccinated against the influenza virus. Keeping your immune system boosted by consuming citrus fruits, and other foods that boost the immune system, staying hydrated, getting at least 6-8 hours of sleep, and taking a vitamin supplement, are all precautions that can be taken to reduce the risk of infection in the work environment. Additionally, practicing good hand hygiene and staying home from work if infected, if unable to say home, another option would be to wear a surgical mask.
Effect of antibacterial drugs on influenza
      Antibacterial drugs also known as antibiotics, are not effective for treating influenza, because the influenza is caused by a virus. Antibiotics should be prescribed for bacterial infection. Prescribing antibiotics unnecessarily leads to increased antibiotic resistance which could result in death (Imanpour et al, 2017). If the patient develops a bacterial pneumonia, then antibiotics may be prescribed at this time.
Predisposition to pneumonia
      Mrs. A.H. is predisposed to pneumonia because of her age, there may also be structural and functional changes in her respiratory systems that put her at risk by reducing he host defenses. Chest wall mobility and lung compliance is decreased and reduced respectively and may lead to the elderly not being able to clear the secretions in their lungs completely which lead to an increase in the workload of the respiratory muscles. Because Mrs. A.H. was infected by the flu her mucociliary function which is her defense against pathogens was already impaired.

Case summary: Mrs. A.H. was admitted to the hospital after she developed severe chest pain, and appeared confused to friends.
Diagnostic test with rationale
      The appropriate diagnostic test for Mrs. A.H. would include, blood work including an arterial blood gas, sputum culture, chest x-ray (CXR). A complete blood count is drawn to see if the patient has a leukocytosis, neutrophil and bands this show the presence of the infection and the inflammatory process. Blood chemistry to see if the patient is dehydrated, also the electrolytes and bicarbonate level to ascertain if the patient is at risk for acidosis. The arterial blood gas is drawn to ascertain the oxygen content in the arterial blood. The lung consolidation decreases the oxygen exchange in the lungs as the alveoli are filled with exudate as a result of the inflammation and vascular congestion. Sometime supplemental oxygen is necessary to keep the oxygen saturation up. A CXR performed to show the distribution of the consolidation as more than one lobe may be affected. The more lobes that are affected the lower the oxygen saturation leading to hypoxia. Sputum is collected and sent for culture and sensitivity to identify the organism and the appropriate antibiotic that the organism is susceptible to (Hubert and VanMeter, 2018). Urine antigen test is also sent to the laboratory for check for Streptococcus pneumonia (Henig and Kaye, 2017).
Probable cause of chest pain and confusion
Chest pain that increases with cough and inspiration is referred to as pleuritic chest pain. In pneumonia pleuritic chest pain is caused by the inflammation of the lung and adjacent parietal pleura. The parietal pleura has somatic nerves, the inflammation triggers the pain receptors resulting in pleuritic pain (Reamy et al. 2017). A probable cause of the patient’s confusion could be hypoxia. The patient has consolidation in the lungs that can be affecting more than one lobe. This consolidation is caused by the exudate in the alveoli, it decreases the oxygen exchange, and the blood flow in the affected lobes. During infection the metabolic rate is higher than normal and there is a greater demand for oxygen. The demand for the oxygen can not be met due to hypoxia this results in metabolic acidosis which leads to confusion in the especially in the elderly (Hubert and VanMeter, 2018).
Probable signs and symptoms as pneumonia develops
      As the pneumonia develops the patient would probably experience other respiratory and systemic signs and symptoms. These systemic signs and symptoms include fever, chills may occur, fatigue, tachycardia, and leukocytosis. Fever and fatigue occur as a result of the infection and the inflammatory process. The white blood cells are also elevated as a result of the immune response and inflammation. The white blood cells release pyrogens that circulate in the blood resulting in the hypothalamic control being reset to a higher level. Because the hypothalamic control has reset to higher than normal, the body tries to increase the body temperature by shivering, the heart rate is also increased resulting in tachycardia (Hubert and VanMeter, 2018). The respiratory signs and symptoms include dyspnea, tachypnea, rales, diminished breath sounds, and productive cough with rust colored sputum. The patient experiences a dyspnea because of the exudate and consolidation in the lungs that interfere with the gaseous exchange across the alveoli, this increases the work of breathing resulting in tachypnea. The productive cough occurs in an effort to remove the build-up of inflammatory exudate that is in the lungs. The rust color is as a result of the red blood cell and found in the alveolar exudate (Hubert and Van Meter, 2018).
Arterial blood gases
      Mrs. A.H. is at risk for both respiratory acidosis and metabolic acidosis. In metabolic acidosis, the arterial blood gas in the early stage of pneumococcal pneumonia for Mrs. A.H. because she has two lobes involved the pH may be normal at first but in the advance stage the patient can experience metabolic acidosis resulting in a pH that is less than normal. The oxygen saturation in the early stage would be slightly decreased but as the infection progress and the inflammation and exudate the hypoxia increases and oxygen saturation greatly decreased, she would also have a low bicarbonate level as the patient experiences metabolic acidosis
ABG: pH 7.30 PaCO2 42 PaO2 50 HCO3 23
Mrs. A.H. can compensate to maintain a normal pH by deep rapid breathing, more acid will be excreted by the kidneys and the bicarbonate absorption will be increased.
Causes of dehydration and its associated complication in pneumonia
      Mrs. A.H. may become dehydrated secondary to high fever, hyperventilation and inadequate fluid intake. Dehydrations cause dry mucous membranes, dry skin, low blood pressure, weak pulse, mental confusion and fatigue. A severe complication of dehydration is acute renal failure (Hubert and Van Meter, 2018).
Treatment and mobility
      The treatment for pneumonia for Mrs. A.H. would include intravenous hydration to help reduce the fever prevent any further dehydration. Intravenous antibiotics to kill the microorganism causing the infection serving to lessen the effects of the infectious process. Supplemental oxygen is also needed to keep the oxygen saturation greater than 92 %. Respiratory treatment may also be ordered to help Mrs. A.H. move her secretion in order to prevent any further complications. Incentive spirometry could also be used to help aerated her lungs. Elderly patients like Mrs. A.H. should be ambulated daily while in the hospital this helps increase the work of breathing and improve the lung expansion, to prevent pooling of secretions which could lead to further complications. Ambulating these elderly patients also prevents them from becoming deconditioned which causes increased weakness.

Respond in 8-9 sentences , 2  schorlay references APA format