*NURSING > SOAP NOTE > Tina jones (T.J) . SOAP Note week 2. Contains Subjective informations; History of Present Illness (H (All)

Tina jones (T.J) . SOAP Note week 2. Contains Subjective informations; History of Present Illness (HPI); Current Medications; Past Medical History (PMHx); Family History (Fam Hx); Review of Systems (ROS).

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SOAP Note Template Initials: TJ Age: 28 Gender: Female Height Weight BP HR RR Temp SPO2 Pain Allergies 170cm 89kg 140/ 81 89 20 98.5 F 97% Choose an item. Medication: Penicillin (rash/hives) F... ood: none Environment: Cats History of Present Illness (HPI) Chief Complaint (CC) “chest tightness” CC is a BRIEF statement identifying why the patient is here - in the patient’s own words - for instance "headache", NOT "bad headache for 3 days”. Sometimes a patient has more than one complaint. For example: If the patient presents with cough and sore throat, identify which is the CC and which may be an associated symptom Onset Intermittent chest tightness the last couple of days after being near cats Location Chest tightness all over Duration Intermittently the past two days Characteristics Chest tightness no pain. Aggravating Factors Worse at night and lying down, cats, and dust. Relieving Factors Proventil inhaler Treatment Proventil 90mcg inhaler 3 puffs every 4 hours. Current Medications: Include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products. Medication (Rx, OTC, or Homeopathic) Dosage Frequency Length of Time Used Reason for Use Proventil (albuterol) Inhalation 90mcg per puff (2-3 puffs) PRN for asthma symptoms Every 4hrs Wheezing and dyspnea . References Include at least one evidence-based peer-reviewed journal article which relates to this case. Use the correct APA 6th edition formatting. Medes, A. (2019). Raising the bar in asthma management. British Journl of Community Nursing, 24 (9), 456-457. http://doiorg.chamberlainuniveristy.idm.org/10.12968/bjcn. 2019 Quirt, J., Hildebrand, K. J., Mazza, J., Noya, F., & Kim, H. (2018). Asthma. Allergy, asthma, and clinical immunology : official journal of the Canadian Society of Allergy and Clinical Immunology, 14(Suppl 2), 50. https://doi.org/10.1186/s13223-018-0279-0 Sottas, C. E., Anderson, B. J., & Holford, N. H. G. (2016). Salbutamol has rapid onset pharmacodynamics as a bronchodilator. Acta Anaesthesiologica Scandinavica, 60(9), 1328–1331. https://doi-org.chamberlainuniversity.idm.oclc.org/10.1111/aas.12769 [Show More]

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