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Chamberlain College of Nursing - NR 509 Soap.Note.Respiratory.TinaJones. (complete updated 2021)

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Chamberlain College of Nursing - NR 509 Soap.Note.Respiratory.TinaJones. (complete updated 2021) S: Subjective Information the patient or patient representative told you. Initials: T. J. Age: 28 Gende... r: Female Height: 170cm Weight: 86kg BMI: 30.8 BP: 140/81 BG: 224 RR: 20 HR: 89 Temp: 98.5 SPO2: 97% Pain (1-10): Denies LMP: 1/14/20- irregular; every 2 moths; or 6 times a year Allergies: YES Medication: Penicillin- rash/hives Food: Denies Environment: Cats and dust- itchy watery eyes, running nose, exacerbates asthma wit sneezing and wheezing. History of Present Illness (HPI) “It feels like it’s been hard to take in air. My chest feels all tight and I’ve been wheezing. I’ve had to use my inhaler a lot, and it doesn’t feel like it’s totally working”. Chief Complaint (CC): Chest tightness inhaler not working Onset: Intermittent chest tightness the last 2 days after being near cats. Location: Chest and Lungs Duration: Two days ago. Experiencing episodes lasting several minutes every 4 hours since original episode. Waking up twice a night with asthma the past 2 nights. Characteristics: Shortness of breath not relieve by inhaler prescribed use; Wheezing, inability to lie flat, dry nonproductive cough; waking at night due to shortness of breath; asthma interferes with activities of daily life. Chest tightness, not pain. Aggravating Factors: Exposure to cats or dust; Burst of physical exertions “when hurrying up or walking upstairs”. Relieving Factors: Usually inhaler, nothing currently Treatment: Proventil 90mcg inhaler 3 puffs every 4 hours Current Medications Medication Dosage Frequency Length of Time Used Reason for Use Proventil 90mcg 3 puffs every 4 hours PRN 25.5 years Asthma: Wheezing, Shortness of breath; Cats Tylenol Gel Caps ES 500mg 1 capsule PRN < few weeks ago Headache Advil 200mg 3 tablets Three Times a day PRN Menstrual Cramps Metformin Unknown 1 tablet BID 1 year age 24 Type 2 Diabetes Past Medical History (PMHx) – Asthma: Diagnosed age 2.5 years Diabetes: Diagnosed age 24 years. Has not taken medications for diabetes for 3 years. Manages diabetes by avoiding sugar and trying to stay active. Foot Wound: A few months ago, states it is healing Hospitalizations: State” A bunch of times as a child for asthma”; last hospitalization was age 16 years. Chest X-ray age 16 years X-ray foot few months ago Surgery: Denies Immunizations: Shots up to date when in school; has not had Flu vaccine this season. Tetanus booster a year ago. Social History Living with her mother in the suburbs, helping her family and saving money to get her own place. Drinks alcohol when out with friends, two or three drinks; Drives a motor vehicle uses her seatbelt Reports low activity level and diminished activity due to asthma. She uses hypoallergenic bedding hygiene, avoids animals and has not pets in the home. She works fulltime and is in school fulltime. Finds support through family, church, and friends. She is helping her mother since her father is deceased a year ago. Low activity level does not exercise other than walking at work and to school Denies tobacco use, e-cigarettes. Reports smoked used to smoke marijuana but doesn’t anymore Family History Mother: Living- Hypertension- Hyperlipidemia; Father- deceased last year- Hypertension- Type 2 Diabetes Sister- living-age 14 years- asthma- Brother- living- Bing and Healthy (Obesity) - unknown Maternal Grandmother- deceased age 73 from stroke; Hypertension- Hyperliidemia Maternal Grandfather- deceased age 80- Hypertension- Hyperlipidemia Paternal Grandmother- Living- Hypertension? Hyperlipidemia Paternal Grandfather- deceased age 60s from Colon Cancer- Type 2 Diabetes (continued) [Show More]

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