SOAP – hypertension, hyperlipidemia, hysterectomy, and CHF – HA W2D1 R1
Type of document Essay 1 Page Subject area Nursing Academic Level Master
Style APA Number of sources/references 2
Order description:
Charli Souza Week 2 Main Post
COLLAPSE
S (Subjective)
A 67 year old female with history of hypertension, hyperlipidemia, hysterectomy, and CHF with last ejection fraction of 55% presents today with chest pain. Patient complains of pain that “feels like someone is squeezing my chest as tight as they can” with pain on the left side of the chest and radiating to the back. Pain is 8/10 pain. Patient is nauseated, but denies vomiting. Per patient, the pain is worse upon exertion and gets better while resting. Chest pain began this morning when she was watering her plants. Patient ignored it until it worsened and she felt short of breath and the pain “really worried me”. Patient complaints of a cough that started last week and has been spitting up green phlemn.
O (Objective)
Vital signs are as follows: T: 37.0, BP 165/98, HR 98, R 26, SaO2 93% on 2L NC. Patient’s skin is pale, diaphoretic. Patient appears to have moments of distress and holds chest while grimacing during conversation.
A (Assessment)
Neurological: patient is alert and orient to person, place, and time. Moves all extremities strong and to command. PERRLA size 3mm. Speech clear. Patient denies headache, numbness, tingling, double or blurred vision.
Cardiac: Heart murmur heard upon auscultation. Heart rhythm regular. 2+ Pitting edema noted in lower extremities from ankles to knees.
Respiratory: Crackles heard upon auscultation throughout posterior chest. Respirations mildly labored. Chest symmetrical.
GI/GU: Bowel sounds present. Patient denies abdominal tenderness. Patient reports last bowel movement this morning. Patient urinating regularly, but states “not that much lately”. Patient currently NPO.
P (Plan)
Current plan at this time is to get 12 lead EKG. Basic Metabolic panel and complete blood count, troponin, CK, lytes, BUN, creatanine, BNP. Will repeat troponin every 6 hours times 3. Keep patient on oxygen. Will prescribe 2mg of morphine for chest pain to give now. Nitroglycerin ordered as needed for chest pain to give every 5 minutes x3. Monitor patient on continuous cardiac monitor to watch for any EKG changes. Chest x-ray. Will plan to give lasix for crackles and edema noted after chest x-ray is resulted. Place foley catheter to monitor strict intake and output.
Questions
First I would ask the patient if the coughing causes any discomfort or worsens chest pain. Many respiratory symtpoms such as coughing can mimic chest pain thought to be cardiac related. Respiratory disorders such as pnemonia or pulmonary edema may cause chest pain symptoms, but are not cardiac related (Bickley, 2017).
A second question I would ask the patient is about her normal physical activity and tolerance to activity. The patient stated that she was outside watering the flowers, but it would be important to know if this is something she does often or if it was the first time she has been doing physical activity. This would allow me to understand if the shortness of breath came from over exersion or if it was only felt after the chest pain began.
Normal findings: patient stated chest pain worsened when coughing. Chest pain subsided when resting.
Abnormal findings: patient stated she was out of breath as soon as she walked outside and has been unable to perform normal activities as she was doing a few weeks prior without being winded. Patient has been coughing up green phlegm for a week.
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