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NU 518: Nursing Comprehensive Health Assessment Example
NU 518: Advanced Nursing Assessment Assignment Instructions Overview: CHA SOAP Note Analysis
In this assignment, students are required to analyze a detailed SOAP Note (Subjective, Objective, Assessment, and Plan) related to a patient’s health condition. The student’s task is to review the provided SOAP Note and critically assess the patient’s health, identify potential differential diagnoses, propose a working diagnosis, and outline a comprehensive treatment plan.
Understanding the SOAP Note:
A SOAP Note, an acronym for Subjective, Objective, Assessment, and Plan, is a structured method of documenting patient information in the healthcare setting. It encompasses the patient’s subjective accounts, objective clinical findings, a professional assessment, and a plan for medical intervention. Through this assignment, students are able to gain hands-on experience in deciphering, evaluating, and making informed decisions based on this vital patient record.
The Student’s Role:
Your role as a student in this assignment is multi-faceted. You will immerse yourself in the role of a seasoned healthcare provider, akin to a nurse or a physician, tasked with assessing and managing a patient’s health. This exercise not only hones your analytical skills but also cultivates the clinical judgment required in real-world healthcare scenarios.
Subjective Data (Health History): Nursing Comprehensive Health Assessment Example SOAP Note
Patient Information:
This is a 70-year-old Caucasian male with insurance coverage. The patient is considered a reliable source of information.
Chief Complaint (CC):
The patient’s chief complaint is, “I have not felt well for the past few days. I have a frequent wet cough, which worsens at night and causes my chest to hurt. I also experience chest pain when I breathe.”
History of Present Illness (HPI):
- Location: The patient experiences chest pain when coughing and breathing, especially during deep breaths.
- Quality: The patient describes the chest pain as sharp and piercing.
- Severity: The intensity of the pain is rated as 7/10.
- Onset: Symptoms began six days ago after attending a dinner party with friends. Initial symptoms included flu-like symptoms, shortness of breath, and fever, which worsened over the next few days. Chest pain is induced by coughing and breathing and persists throughout the day.
- Modifying Factors: Alcohol and smoking worsen the cough. Environmental factors like temperature and humidity also affect the condition. Drinking hot peppermint and ginger tea helps reduce the severity of the cough and chest pain.
- Associated Manifestations: The patient also experiences fatigue and a loss of appetite.
- Additional Social or Medical Information Relevant to the CC: The patient has poor dietary habits, does not exercise, smokes 1-2 cigars daily, and consumes alcohol regularly. His diet mainly consists of red meat and vegetables, with limited fruit intake.
Past Medical History:
- Medications: The patient is currently not taking any medications.
- Allergies: The patient denies any allergies.
- Childhood Illnesses: He had chickenpox at the age of six, from which he fully recovered.
- Adult Illnesses: Diagnosed with a urinary tract infection at age 56 but recovered with treatment. He was obese from 19 to 23, after which he maintained a healthy lifestyle until age 68.
- Past Hospitalizations/Surgeries/ED Visits: He had hip replacement surgery in 2013 due to a car accident caused by drunk driving.
- Injuries/Accidents: Involved in a car accident in 2013 due to driving under the influence.
- Health Maintenance: Received COVID-19 vaccinations in 2020 and 2021, childhood vaccines, deworming every six months, and an annual flu shot. Scheduled for a colonoscopy later this year.
Family History:
- Grandparents died of old age.
- Father died during the Korean War at age 32.
- Mother died at age 78, had hypertension.
- One older brother, aged 82, in good health.
Personal and Social History:
- Married with one daughter (43 years old) and two grandsons (8 and 13 years old).
- Lives in an upper-middle-class suburban neighborhood.
- Manages a multimillion-dollar real estate company.
- Rarely attends church.
- Enjoys golf and sports.
- Smokes cigars and drinks alcohol regularly.
- Has not exercised for the past two years.
- Irregular sleep pattern.
- Occasionally drinks coffee.
- Owns firearms for security.
- Ate steak, broccoli, and cake for lunch and dinner yesterday, had eggs and bacon for breakfast today, and drank hot peppermint tea.
Review of Systems:
- General: The patient appears confused and experiences chest discomfort during coughing or breathing. Fatigue and loss of appetite are also reported.
- Head: Denies headaches and dizziness.
- Skin/Hair/Nails: Urticarial rashes present on the skin. Hair and nails appear normal.
- Eyes: Uses corrective lenses for nearsightedness.
- Ears: Hearing is generally normal, but slightly clogged since symptoms worsened.
- Nose: Reports a running and congested nose, worsened at night.
- Throat: Admits to a sore throat.
- Neck: Experiences pain and muscle spasm.
- Breasts: Not applicable.
- Respiratory: Persistent wet cough, worsens at night, accompanied by sharp chest pain when coughing or breathing. Wheezing sounds when breathing.
- Cardiovascular/Peripheral Vascular: Experiences rapid and irregular heartbeats.
- Gastrointestinal: Reports nausea and vomiting for the past three days.
- Urinary: Acknowledges decreased urination.
- Musculoskeletal/Back: Acknowledges muscle weakness and soreness.
- Psychiatric: Confusion reported but denies suicidal thoughts.
- Neurologic: Denies headaches.
- Hematologic: Blood pressure is dangerously low.
- Endocrine: Exhibits decreased levels of triiodothyronine and thyroxine levels.
Objective Data (Physical Examination): Nursing Comprehensive Health Assessment Example SOAP Note
General Survey:
A 70-year-old Caucasian male who appears confused and experiences chest discomfort during coughing or deep breathing.
Vital Signs/Height/Weight/BMI:
- Blood Pressure: 150/90 mm Hg
- Heart Rate: 91 beats per minute
- Respiratory Rate: 21 breaths per minute
- Temperature: 96°F
- Weight: 160 lbs
- Height: 5’9”
- BMI: 29
Skin/Hair/Nails:
Skin is free from discoloration or lesions.
Head:
No apparent abnormalities or lesions.
Eyes:
Red eyes, responsive pupils, round shape.
Ears:
No visible abnormalities.
Nose/Sinuses:
Yellow mucus discharge after coughing.
Mouth/Throat:
Red throat.
Neck:
Signs of muscle spasms and stiffness.
Lymphatic:
Acute inflammation in the mediastinal lymph nodes.
Breasts:
Reports dull breast pain.
Thorax:
Slight inflammation in lung lining, yellow mucus production when coughing, wheezing sounds during breathing.
Cardiovascular:
S1 is louder than S2.
Abdomen:
Occasional severe abdominal pain.
Musculoskeletal:
Weakness and muscle soreness.
Neurologic:
Confusion reported, but no suicidal thoughts.
Genitalia:
Urinary tract infection is suspected.
Lab Test:
Pulse oximetry test indicates blood oxygen levels below the standard range.
Assessment:
Differential Diagnoses:
- Pneumonia: Symptoms include chest pain, shortness of breath, productive cough, and wheezing noises during breathing, making this a likely diagnosis.
- Chronic Obstructive Pulmonary Disease (COPD): Characterized by shortness of breath, persistent wheezing, and mucus production, which align with the patient’s symptoms.
- Myocardial Infarction (Heart Attack): Considered due to chest pain radiating to arms and age, although symptoms like cough and wheezing make this less likely.
- Pleurisy: Inflammation of the pleura causing chest pain, exacerbated by coughing, aligns with the patient’s symptoms.
- Pulmonary Embolism: Less likely due to the absence of sudden onset symptoms.
Working Diagnosis on the Nursing Comprehensive Health Assessment Example:
Pneumonia is the working diagnosis due to symptoms such as productive cough, yellowish mucus, muscle fatigue, chest pain during breathing and coughing, wheezing, and confusion, which can be common in elderly individuals with pneumonia.
Plan:
- Encourage the patient to adopt a healthier lifestyle by quitting smoking, maintaining a healthy diet, and regular exercise.
- Suggest warm beverages and steamy baths to help open airways.
- Advise the patient to avoid smoke exposure, including wood smoke.
- Prescribe medications:
- Amoxyclav (Penicillin) 1gm twice daily for five days to treat the infection.
- Prednisolone (corticosteroid) 10mg three times daily for 3 days to manage inflammation.
- Meloxicam 15mg twice daily for 3 days for pain management.
- Vitamin C 1gm once daily for a month to boost immunity.
- Schedule a follow-up appointment after seven days to assess treatment effectiveness, monitor for side effects, and conduct another pulse oximetry test and chest examination.
- Support smoking cessation efforts with Nicorette and weekly monitoring initially.
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