Soap Analysis: Adult with Heart Failure and COPD

Focused Soap Analysis: Adult with Heart Failure and Chronic Obstructive Pulmonary Disease

Patient Initials: P.S

Age: 57 years old female

Ethnicity: African American

Initials of Provider:

Clinical Setting: Outpatient

Patient Status: ____New _x__Established

Subjective Data

Chief Complaint

P.S is a new patient, who has come to the hospital coughing and complaining of chest pain. The woman says, “My chest feels full, and it is painful when I cough. I have been producing greenish yellow mucus; it was pink with some blood yesterday. Look, my feet and hands are also swollen and they have been doing so for quite some time now.” She coughs and continues, “When I am resting while seated, I breathe well, but when I start walking, or when I sleep, I cannot breathe well. This disease has made me lose weight so much.”

History of Present Illness

P.S started to experience several episodes of coughing three years ago. She produced greenish-yellow sputum when coughing but she did not attend any hospital because the closest hospital was far from her residence. The symptoms subsided after two months and P.S thought she recovered. Two years ago, the woman started coughing again while experiencing pain in the chest. She went to buy Chlorpheniramine and ibuprofen over the counter. She does not remember the length of the time she took them, but she says she only took the medication when she experienced the symptoms. Later, P.S experienced improvement. However, chest pain, coughing, and shortness of breath developed 10 months ago. P.S confirms that she has been smoking and reiterates that she has not attended the hospital because it was far. Seven days ago, the symptoms worsened, and the woman experienced severe dyspnea on exertion with increased chest pain when coughing. The two symptoms have prompted her to seek medical care. Then, she states that she has been noticing progressive weight loss, but she did nothing about it, as she thought it was normal. As she speaks, she is holding her chest while coughing with labored breathing.

Review of Systems:

Constitutional: Positive for fatigue, progressive weight loss, and fever. Denies chills

Head/face: Denies a headache, dizziness, or head injury.

Eyes: Denies retinal hemorrhages, blurry vision, eye pain, double vision, or any discharge from both eyes

Ears: Denies otorrhagia, tinnitus, or otalgia.

Nose: Positive for rhinorrhea. Denies sinusitis or epistaxis.

Mouth: Denies xerostomia, glossodynia, gingival ulceration, or gingival bleeding

Throat: Positive for a sore throat. Denies voice hoarseness or pharyngitis

Neck: Denies swollen neck, neck pain, or neck stiffness

Respiratory: Positive for wheeze, greenish sputum production, blood tinged yellow phlegm, and orthopnea. Also positive dyspnea and chest pain. Denies hemoptysis.

Cardiac: Positive for palpitations, edema, chest pain. Denies unconsciousness

Breast: Denies lumps, breast pain or lesions

GI: Denies tenesmus, constipation, diarrhea, or melena.

GU: Denies polyuria, dysuria, hematuria, or urethral discharge.

Reproductive: Denies erectile dysfunction

Musculoskeletal: Denies myalgia, arthritic complaints, back pains, or muscle stiffness.

Skin/Integument: Denies any rash or itching.

Psychiatric: Positive for anxiety. Denies thought disorders, depression, homicidal ideation.

Neurological: Positive for dysgeusia. Denies blurry vision, weakness, fasciculations, or seizures.

Endocrine: Positive for weight loss. Denies polydipsia, polyuria, or thyrotoxicosis.

Hematologic/Lymphatic: Denies petechiae, or anemia.

Allergic/Immunologic: Denies any allergic reaction, asthma, hives, or eczema

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Past History

PMH: Has been having wheezing, a cough and production of mucus for over two years. Never attended hospital due to distance and lack of proper means to access it.

PSH. Underwent a cesarean section once 20 years ago, when delivering her first born.

Past Psychiatric Hx. No psychiatric history noted.

Obstetrical History: N/A

Hospitalizations: Has never been hospitalized.

Medications: Been using ibuprofen and Chlorpheniramine, where necessary; but has not been following the prescription schedule. Is unable to remember the dosage.

Allergies: Has no known allergies

Dietary Hx: Eats more meat and fatty foods. Confirms that she uses little calories and rarely drinks water. Never abuses alcohol but smokes 15 cigarettes per day.

Immunizations: All immunizations were given

Health Promotion: Has poor dietary habits but does not have access to the health facility. She says that she relies on her knowledge to handle her health problems. She perceives freedom from pain as good health.

Functional Status: Her ADLs are always interrupted due to dyspnea on exertion. Her last born daughter helps with the ADLs.

Family History

Woman’s father died due to a road accident, and her mother died of the end stage renal disease as complications of diabetes mellitus type 2. She has a sister and a brother, both in a satisfactory state of health. No other positive family history of chronic illness is recorded. She is the only member of family with the chronic condition.

Social History

P.S is a hairdresser in her neighborhood. She has been doing the job for the last 30 years. She divorced her husband ten years ago due ‘irreconcilable differences”, as she terms it. She has two daughters: the first one is married and the second one has just completed college. P.S. stays with her last-born daughter, who has been helping her with house chores. P.S also says she eats fewer calories and consumes meat on a daily basis. P.S indicates that she rarely attends church, but tries to attend church at least once a month. She says that smoking is a habit that she has been having since her 20s and she has never stopped to smoke despite several warnings from people. P.S confirms that she has several friends, who smoke like her by encouraging her to smoke.

Cultural Influence on Care: Does not articulate any cultural issues that might affect any therapeutic regimen.

Level of History

P.S has several problems including chest pain, shortness of breath, fatigue, sputum production. She also experiences palpitations and dyspnea on exertion. Additionally, she produces blood-tinged phlegm; she produces greenish sputum, when she coughs. She is anxious and often loses food appetite. From the review of the symptoms, the respiratory, cardiac, psychiatric, and neurologic systems are involved. Therefore, the level of history is detailed.

Objective Data

Vital Signs: RR: 16bpm, BP: 122/90 mmHg, Temp: 100F

PaCO2: 90%, Pulse: 82bpm irregular, pain score: 8/10

Ht: 5’5.”

Wt: 127lbs

BMI: 21.1kg/m2

Constitutional: The woman seems to have normal weight but is fatigued, has edema of the extremities and the face.

General: P.S. appears oriented despite decreased alertness and chest pain.

Physical Examination

Head/face: Free from tenderness, deformities, or lesions with normocephalic presentation.

Eyes: Pink conjunctiva, intact visual acuity with the non-icteric sclera. Has normal optic discs free from hemorrhages.

Ears: Translucent Tympanic membrane with no masses or lesions.

Nose: Pink mucosa, looks edematized. Has rhinorrhea. No epistaxis noted.

Mouth: No xerostomia identified. Has normal dentition with no periodontal diseases. No lesions or bleeding in the mouth and the gums.

Throat: Throat inflamed and appears reddened. No lesions noted in the throat. Moreover, no inflammation of the Tonsilar Fossa.

Neck: No lesion on the neck. Palpable trachea.

Respiratory: Wheeze noted on auscultation approach explained by Ball, Dains, Flynn, Solomon, and Stewart (2015). Crackles heard for a length of 0:09 minutes. Cough is accompanied by the production of blood stained phlegm and greenish yellow discharge concurrently. Has dyspnea.

Cardiac: Palpitations heard, and edema of the lower and upper extremities noted. No cardiomegaly. No murmur or dysrhythmias.

Breast: No lumps or lesions.

GI: Normal bowel sounds. No tenderness or masses noted upon palpation.

GU: Urinary meatus noninflamed and has normal vaginal mucosa.

Musculoskeletal: Non-symmetrical extremities due to edema.

Skin/Integument: Uniform pigmentation of the skin. Free from lesions

Psychiatric: Has decreased alertness and anxious but is oriented to place and time.

Neurological: Intact cranial nerves. No blurry in vision. Leans forward due to chest pain.

Hematologic/Lymphatic/Immunologic: Non-palpable lymph nodes.

Level of Physical Objective Exam

This exam has affected different systems. Wheeze, dyspnea, coughing, and crackles have been identified in the respiratory system. Furthermore, the psychiatric exam notes decreased alertness and anxiety. Dysrhythmias, palpitations, and edema have been identified as abnormalities of the cardiovascular system. A general exam indicates fatigue. Therefore, the level of physical exam is detailed.

Laboratory Data Already Ordered and Available for Review

Diagnostics Already Ordered and Available for Review

FEV1/FVC results indicate 60% that confirms inadequate lung function

Assessment

1) Main Diagnosis/Problem: Heart Failure secondary to COPD

2) Additional Health Problem/Dx: Dysrhythmias

3) Differential Diagnoses for top diagnoses: Emphysema

4) Risk Factors: Smoking and little physical exercise

Plan

Additional Laboratory Tests or Diagnostic Data Needed

For Heart Failure

1. Serum electrolyte level

2. (UA)

3. Liver function tests LFTs)

4. ECG, 12 lead

5. BUN

6. Creatinine levels

For COPD

1. Chest X-ray

2. Arterial Blood Gas Analysis

3. CT scan of the lungs

Pharmacologic Management

Drug, dose, route, frequency, Disp amount

For heart failure (Yancy et al., 2013)

Admit and begin on:

Enalapril 2.5mg by mouth once a day. Dispense 56 tablets to be taken for 12 weeks, with 14 tablets in each packet for each week.

Digoxin 500 mcg by mouth once a day. Dispense 14 tablets for one week then schedule the patient for monitoring after seven days in order to determine if the patient needs more drugs.

Aldactone 25 mg by mouth once a day. Dispense seven tablets in one sachet for seven days and observe for seven days in order to monitor the progress.

For Chronic Obstructive Pulmonary Disease (Lee, Kim, & Tagmazyan, 2013).

Albuterol 200mcg inhaled by mouth every 4 hours. Dispense 20 ml bottle and explain the method of inhalation.

Azithromycin 500 mg by mouth once a day for three days. Dispense 250 mg tablets (6 of them).

Fluticasone inhalation aerosol 400 mcg by mouth twice a day. Dispense 15 ml bottle and explain the mode of spray.

Non-Pharmacologic Management

The nurse can utilize various non-pharmacological measures to manage heart failure and COPD of P.S. Regarding heart failure, the first approach is to ensure sodium restriction. Rabelo et al. (2012) promotes this method, as the most appropriate nonpharmacological approach to preventing fluid overload in patients with heart failure. Thus, the nurse can restrict it to 1500 mg per day. Additionally, the nurse should monitor her urine output and limit fluid intake, since it can contribute to edema (Rabelo et al. (2012). Then, Rabelo et al. (2012) further indicate that in this case, the nurse can measure and record weight as a baseline for monitoring in order to determine if the patient is gaining weight. Weight gain can occur because of edema that indicates that the patient needs further medical and nonpharmacological care in order to reduce fluid overload.

Regarding COPD, the nurse should first promote pulmonary rehabilitation by helping P.S to do physical activity. Safka (2015) ascertains that this method is one of the cost-effective nonpharmacological measures to increase patient participation in care and facilitate breathing by managing dyspnea efficiently. The nurse can also provide non-invasive ventilation using a mask because it can facilitate breathing (Safka, 2015). The focus of the nonpharmacological care regarding COPD for P.S. should relate to enhancement of breathing and significant reduction of dyspnea.

Complementary Therapies

Some of the suitable complementary therapies for the patient include immunizations, helping with smoking cessation, giving oxygen and providing adequate nutrition. According to Safka (2015), inactivated influenza vaccines are the most appropriate medications in helping the patient to have reduced incidences of exacerbation in COPD. Furthermore, this approach is efficient in reducing exacerbations in heart failure. Safka (2015) further indicates that smoking cessation is useful because it prevents the progression of COPD and heart failure. According to Safka (2015), providing oxygen, particularly, by a mask is also efficient because it prevents dyspnea that is caused by both COPD and heart failure. Finally, ensuring proper nutrition, particularly, the provision of more calories and proteins is crucial, since the woman is underweight and she utilizes much effort in order to breath. In implementing this approach, the nurse can collaborate with the nutritionist and determine the food nutrients the patient needs. Later, the nutritionist can give the feeds, and the nurse can monitor the improvement of the patient and monitor her weight.

Health Education

Health education for P.S can be detailed because she is not aware of the causes of the symptoms, the risk factors for her poor health behavior, and the drugs used to manage her condition. The nurse can begin by explaining the causes and consequences of the symptoms to P.S. For instance, according to Rabelo et al. (2012), heart failure can cause dyspnea, edema, and fatigue. If the symptoms are not treated as soon as possible, they can increase in severity that might lead to death. The nurse should compile this evidence-based information and teach the client, while asking the questions in order to evaluate whether the woman understands information correctly. Most importantly, the nurse should be careful, while explaining the consequences to the patient, in order to avoid making the woman feel anxious.

Moreover, the nurse can teach the patient about the importance of developing good health-seeking behavior. For instance, in the subjective data, P.S says that she has never turned to the hospital for help. When the woman feels pain at home, she buys medication over the counter; when the woman feels tired, she goes to sleep. Such measures have been inappropriate in managing her health condition that has resulted in complications, which have made the woman come to the hospital. Thus, the nurse can advise P.S. to visit the health facility any time she experiences discomfort at home because her conditions have become chronic. Further, the nurse can stress the importance of complying with the health advice.

Furthermore, the nurse can teach P.S about the medication compliance. P.S has not attended any facility and has not complied with over the counter medications despite the prescriptions. Therefore, the nurse can use simple terms in educating the patient about the therapeutic action of drugs, the possible side effects, and the consequences of defaulting the drugs.

Finally, the nurse should teach the woman about the nonpharmacological therapies. For instance, the nurse can tell the patient that salt has sodium and it increases the amount of fluid in the body and further leads to swollen feet and difficulties in breathing if consumed in excess (Rabelo et al., 2012). The nurse can educate the patient that immunization is necessary as it can prevent breathlessness. Moreover, the nurse should use informal language in providing information since the patient is unaware of the disease process.

Referrals

While P.S. is in the hospital, the nurse can request for the examination of the woman by the pulmonologist immediately after the admission and nursing management. The immediate review by the pulmonologist is necessary, since the patient might have developed many complications due to the delayed treatment. If the pulmonologist is not in the hospital, the nurse can write a referral form and include the medication, nonpharmacological therapies, complementary therapies, and a health advice. Moreover, the nurse should ensure that the referral process does not interfere with the schedule of the drug dosages unless the pulmonologist changes the regimen. The nurse can also request the examination of the patient by the electrophysiologist, who can assess the extent of heart failure and offer appropriate advice in the alteration of the initial management.

Follow-up Appointment

The nurse should consider admitting P.S since adherence to the medication is not guaranteed at home. During the hospitalization, the nurse can continuously monitor compliance with the medications. Additionally, the nurse can teach the client the importance of adhering to the medications and complying with the health advice. Upon agreement with the physician and the nutritionist, who provide the feeds, the nurse can discharge P.S; the nurse should schedule a return date in order to assess the adherence to the medication and symptom management. Upon the appointments, the nurse can issue more drugs determined by the condition of the client and offer advice on drug compliance and proper health seeking behavior.

Encounter Final Level of Decision Making

Heart failure and COPD in P.S. have affected various systems of the body. The woman has edema of the feet and hands. Additionally, she is experiencing palpitations and has a persistent painful cough that produces blood-tinged phlegm. The patient has a wheeze; she also experiences chest tightness. Despite the swollen feet due to edema, the patient is underweight and appears malnourished. Moreover, the woman has fatigue and chest tightness with cyanosis. Consequently, P.S. has various signs and symptoms that can deteriorate her health; thus, the final level of decision-making is of high complexity.

Billing

Status: New

Level of:

History: detailed; code 99203

Physical exam: detailed; code 99203

Decision-making: High complexity; code 99205

Analysis

Subjective and Objective Data Supporting the Diagnosis

In the subjective data, P.S indicates that she is having difficulties in breathing, especially, when sleeping and working. Additionally, the woman experiences palpitations, and her heartbeat is irregular. An objective analysis reveals swollen extremities and a wheeze with pink phlegm. Yancy et al. (2013) provide guidelines that indicate that dyspnea, palpitations, and edema represent the symptoms of heart failure. Accordingly, it is appropriate to diagnose heart failure in P.S.

Additionally, the patient experiences chest tightness and a painful cough. The subjective data indicates that the woman smokes. On auscultation, P.S has a wheeze with crackles, and she produces greenish sputum. Moreover, the woman also has dyspnea. Miravitlles et al. (2016) provide guidelines that confirm that such symptoms with smoking as a risk factor are significant in diagnosing COPD. Therefore, the patient has COPD with heart failure as comorbidity.

Plan for the Main Diagnosis

The plan for the primary diagnosis includes further laboratory tests, pharmacologic and nonpharmacologic management, complementary therapy, health education, and follow-up. Regarding the laboratory tests, Yancy et al. (2013) confirm that such measures as serum electrolyte level, urinalysis, and electrocardiogram are efficient in ascertaining heart failure. Therefore, the nurse can plan to utilize the approaches in order to confirm heart failure. Yancy et al. (2013) further verify that such drugs as enalapril, digoxin, and Aldactone are efficient in managing heart failure. Accordingly, the nurse can use such drugs, implement such complementary therapies as immunizations, and educate the patient to embrace proper health seeking behavior. Most importantly, the nurse should carry out a follow-up in order to ensure that the patient complies with the drugs.

The management of COPD should also be concurrent with heart failure. Miravitlles et al. (2016) ascertain that such procedures as Lung function tests are efficient in confirming COPD. In fact, such administration of drugs as albuterol, fluticasone, and azithromycin can prevent dyspnea, cure inflammation and eliminate the infection. Similar to the management of heart failure, the nurse should perform such complementary therapies as providing oxygen and educate the patient on drug and health advice compliance. Finally, a referral of the patient to the appropriate specialists and scheduling follow-up can improve woman’s health outcome.