May 30, | nursing, med, NURS, Paper
Tina Jones shadow health SOAP Note
SOAP Note Format
Patient Information:
Tina Jones is an obese 28-year-old African American female, who comes in today for evaluation and treatment of asthma exacerbation.
S.
CC (chief complaint)
“I came in because I’ve been having breathing problems, and my inhaler just isn’t working the way it normally does.”
HPI: include all the information regarding the CC using the OLDCART format.
Onset: 2 days ago
Location: Nose and lungs
Duration: 2 days
Characteristics: Chest feels tight and she has noticed some wheezing, with non-productive, dry cough
Aggravating Factors: Worse at night when she is lying down on her back.
Relieving Factors: Albuterol inhaler 3 puffs every four hours (however, does not feel like it is completely under control). Drinking water helps with the cough.
Treatment: Albuterol inhaler 3 puffs every four hours
Current Medications:
Albuterol 90 mcg/spray 3 puffs every four hours as needed for wheezing when around cats
Allergies:
Penicillin= rash
Cats and dust= runny nose, itchy and swollen eyes and increased asthma symptoms
Ms. Jones denies any food or latex allergies
PMHx:
Asthma diagnosed at age 2 ½
Last time hospitalized for asthma was when she was a little girl, has never been intubated
Type 2 Diabetes Mellitus diagnosed at age 24
Menarche at age 11
Sexually active with men only, last tested for STIs four years ago, never tested for HIV
Soc Hx:
Tine is a supervisor at Mid American Copy and Ship she has been working there since she was in high school. She is single and never been pregnant. Tine is a non-smoker and reports drinking alcohol socially with friends once a month. Reports the use of Marijuana from age 18 to 20. Tina is part of a book club and enjoys going to church talks. She currently lives with her mother and sister.
Fam Hx:
Tina reports her sister also has asthma. Denies any family history of COPD, or any throat or neck surgeries. Her mother is living and has high cholesterol and hypertension. Her father passed away in a car accident a year ago. Father had high cholesterol, hypertension and type 2 diabetes. Her bother is obese and her sister has asthma. Tina denies any family history of eczema or COPD.
ROS: cover all body systems that may help you include or rule out a differential diagnosis You should list each system as follows: Constitutional: Head: EENT: etc. You may list these in paragraph format or bullet format. Always document the systems in order from head to toe. You may focus the ROS to match the chief complaint unless you are doing a complete health history.
CONSTITUTIONAL: No weight loss, fever, chills, weakness or fatigue.
HEENT: Eyes: No visual loss, blurred vision, double vision or yellow sclera. 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: Reports shortness of breath, chest tightening, wheezing and non-productive dry cough
GASTROINTESTINAL: No anorexia, nausea, vomiting or diarrhea. No abdominal pain.
GENITOURINARY: No burning on urination, never been pregnant. Last menstrual period started yesterday.
NEUROLOGICAL: No headache, 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.
PSYCHIATRIC: No history of depression or anxiety.
ENDOCRINOLOGIC: No reports of sweating, cold or heat intolerance. No polyuria or polydipsia.
ALLERGIES: History of asthma, with allergy to cats, dust and penicillin.
O.
Physical exam: See above ROS.
Diagnostic results: None
A.
Differential Diagnoses
Asthma exacerbation
No intervention is self-evident. Provide a rationale and evidence based in-text citation for each intervention
Diagnostics:
Order PFTs to be completed after exacerbation to have a baseline
Obtain oxygen saturation
Rx: list treatments and medications you will order and “continue previous meds” if pertinent. State dosages, length of treatment and reason for choosing a specific treatment or drug.
Tina would be started on corticosteroids such as Flovent (44mcg per actuation) 2-4 puffs inhaled bid
Continue with Albuterol inhaler as well.
Education: think about covering yourself legally; also indicate when written instructions are given.
Tine would be educated on the importance of seeing her asthma doctor regularly to manage and treat asthma symptoms.
Encourage her to keep a log of her asthma symptoms and triggers, and bring to her next visit for review.
Referral/Consults:
Ms. Jones would be referred to an Allergist for evaluation and treatment.
Follow up: indicate when patient should return to clinic and provide detailed instructions indicating if the patient should return sooner than scheduled or seek attention elsewhere.
Follow up appointment would be in 2-4 weeks to review asthma log and make sure medications are helping.
Reference
Prieto Centurion, V., Huang, F., Naureckas, E. T., Camargo, C. J., Charbeneau, J., Joo, M. J., & … Krishnan, J. A. (2012). Confirmatory spirometry for adults hospitalized with a diagnosis of asthma or chronic obstructive pulmonary disease exacerbation. BMC Pulmonary Medicine, 1273. doi:10.1186/1471-2466-12-73. Retrieved from: http://web.a.ebscohost.com.chamberlainuniversity.idm.oclc.org/ehost/pdfviewer/pdfviewer?vid=4&sid=285efade-b569-4623-8faf-d8f0d3ad546f%40sessionmgr4007
May 30, | nursing, med, NURS, Paper
NRS 429VN: Topic 1 DQ 2 – Health promotion model used to initiate behavioral changes
NRS 429VN: Topic 1 DQ 2 – Health promotion model used to initiate behavioral changes
Describe a health promotion model used to initiate behavioral changes. How does this model help in teaching behavioral changes? What are some of the barriers that affect a patient’s ability to learn? How does a patient’s readiness to learn, or readiness to change, affect learning outcomes?
Re: Topic 1 DQ 2
The health promotion model was developed in 1982 by Dr. Nola J. Pender. The theorist, Nola J. Gender. Pender believed that the goal of nursing care was to help their patients achieve optimal health and well-being. The health promotion model claims that each individual’s characteristics and life experiences have a direct impact on their actions and decisions regarding their health (Butts & Rich, 2018, p.446) NRS 429VN: Topic 1 DQ 2 – Health promotion model used to initiate behavioral changes.
Pender’s health promotion model concentrates on three major categories: individual characteristics and experiences, behavior-specific cognitions and affect and lastly, the behavioral outcomes (Butts & Rich, 2018, p.446). The second category involves the behavior-specific cognitions and affect which have a direct impact on the individual’s motivation for change (Butts & Rich, 2018, p.447). Behavior plays an important role in people’s health. Behaviors such as , smoking, poor diet, lack of exercise and sexual risk-taking can cause a large number of diseases. Interventions to change behavior have enormous potential to alter current patterns of the disease that can be acquired from us behavior mentioned above. The goal of the health promotion model is to stimulate a behavioral change that results in a positive health outcome.
Barriers such as individuals’ inability to see or hear properly, culture, language, and religion, etc. can affect a patient’s ability to learn. teaching patients about their respective illnesses and finding ways to engage patient on how to best manage these illnesses guide the patient to pursue better health as well as suitable health.
Learning readiness refers to how likely a person is to seek out knowledge and participate in behavior change. Individuals go through various stages in order to adopt or maintain a new health behavior. In the contemplative stage, the person is generally not aware of a problem or ready to act. Many factors influence a patient’s readiness to learn. Anything that affects physical or psychological comfort such as pain, fatigue, anxiety, fear also affects a person’s ability and motivation to learn NRS 429VN: Topic 1 DQ 2 – Health promotion model used to initiate behavioral changes.
In order for a behavioral change to occur and be maintained it must be self-initiated (Butts & Rich, 2018, p.449). One must consider the individual’s previous behavior and characteristics that can have a direct influence on future health-promoting behavior. Perceived personal value or benefit, as well as, self-worth can be a driving focus to achieve participation (Butts & Rich, 2018, p.449). A strong indication for commitment to health-promotion behavior can be achieved when others in their environment support and display the behavior.
Reference
Butts, J. B., & Rich, K. L. (2018). Philosophies and Theories for Advanced Nursing Practice. Burlington, MA: Jones & Bartlett Learning.
response
you made some great points in your DQ. Nurses play an important roles in teaching or educate patients with information about healthy behavior. Many health conditions can be prevented by simple lifestyle changes. To make teaching more effective, nurses need to know about patient’s learning factors such as readiness, environment factors, health status, and cultural awareness. Nurses also use the health belief model to motivate people to take positive health actions. The desire to avoid a negative health consequence can be used as the initiative motivation. Receptiveness of the patient needs to be present in order for the patient to be able to absorb the knowledge that you are implanting to them. The plan for patient education should be checked for its efficacy and should be analyzed and acted upon after implementation. Nurses should also reassess the way that the patient is learning and if they are indeed learning at all. Therefore, a follow up conversation at some point should be implemented to assure their understanding NRS 429VN: Topic 1 DQ 2 – Health promotion model used to initiate behavioral changes.
response2
That is a very important point you stated, “a strong indication for commitment to health promotion behavior can be achieved when others in their environment support and display the behavior.” Including a family member or caregiver at discharge or for education on diagnosis management, helps support the patient. Family members can enhance, reiterate and assist the patient to wellness by implementing new information learned to improve health. Outcomes can be better reached when there are support people available whom may also benefit from change.
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response 3
In regards to Penders model, one of the important factors in health promotion is experience as you stated. Experienced behaviors will determine how well a patient or family unit is willing to change. As Nurses sometimes we make a less than meaningful attempt to teach a patient and the nurse might feel rushed to provide the information. Previous experiences in regards to promoting health changes, or the approach that is given plays a role. In health promotion is valuable to also assess past experiences with interactions that patient has had with health professional NRS 429VN: Topic 1 DQ 2 – Health promotion model used to initiate behavioral changes.
