[SOAP NOTE] NURS 6551 Practicum Experience Journal Week 4 Latest 2021
Journal 3 – Soap Note
Walden University December 24, 2017SOAP NOTE:
... [Show More] HYPERTENSION
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NURS 6531 Practicum Experience Journal
Student Name: Jacqueline Johnson
E-mail Address: [email protected]
Practicum Placement Agency’s Name: Dallas County Rural Health
Preceptor’s Name: Demetric Childs-Hicks, CRNP
Preceptor’s Telephone: 334-877-1488
Email address: [email protected] NOTE: HYPERTENSION
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Patient Initials: XX
Age: 31
Gender: F
SUBJECTIVE DATA:
Chief Complaint (CC): “I’m here for my follow up on my blood pressure, and to review
my labs.”
History of Present Illness (HPI): XX is 31-year-old African American with new onset
of diabetes and hypertension. Alert and oriented. Denies any history of any other
discomfort. Return to clinic for two weeks follow-up for newly diagnosed high blood
pressure and diabetes.
Medications: Lisinopril10mg daily
Metformin 500mg twice daily
Allergies: Denies Allergies
Past Medical History (PMH): Hypertension, Type 2 Diabetes.
Past Surgical History (PSH): Denies Surgical History. Report only hospitalization is for
childbirth.
Personal/Social History: Pt. is a married mother of three who works part-time in retail.
Resides in a three-bedroom home with husband and three children. Pt. has been married
for 5 years. Husband is employed as a trucker and spend a lot of time on the road.
Children are 4-year-old daughter, 9-year-old son, and 11-year-old daughter. Pt. report it is
a monogamous relationship. Denies alcohol, tobacco, or illicit drug use. Denies exposureSOAP NOTE: HYPERTENSION
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to second-hand smoke. Began an exercise program after diagnose of HTN and DM,
which include daily walks and gym membership.
Immunization History: Immunization are up-to-date. Flu vaccine given at this clinic,
October 2017
Significant Family History: Both parents are living. Mother (58y.o.) has a history of
DM, HTN, obesity, and hyperlipidemia. Father (56y.o.) has a history of HTN and
seizures. Pt. has 3 living siblings. Sisters (27 and 25y.o), no health history. Brother
(33y.o.) has DM and HTN. Maternal and paternal grandparents are deceased, causes are
unknown.
Review of Systems:
General: Alert and oriented. No acute distress. Well-groomed and appropriate.
HEENT: Denies dizziness, lightheadedness, vision changes, double vision,
hearing changes, nasal drainage or headaches. Denies sore throat or swallowing
difficulties.
Neck: Denies neck stiffness.
Breasts: N/A
Respiratory: Denies difficulty breathing. Resp even and unlabored.
Cardiovascular/Peripheral Vascular: Denies chest pain, palpitations, or
swelling on extremities.
Gastrointestinal: Denies nausea, vomiting, changes in appetite or bowel
movements.
Genitourinary: Report frequency in urine has improved. Denies incontinence.SOAP NOTE: HYPERTENSION
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Reproductive: Reports monogamous relationship with husband of 5 years. GYN
last check-up was June 2017 with gynecologist and pap smear was in 2016. No
contraceptive. Report husband had a vasectomy. Regular menses, with 21-28-day cycle
that lasts 3 to 5 days.
Musculoskeletal: Denies joint pain, aches, deformities, or injuries.
Psychiatric: Denies anxiety or depression.
Neurological: Denies neurological changes or discomforts. No loss of
consciousness or injury. Denies headaches.
Skin: No breaks in integrity. No dryness, temperature changes, or discolorations
noted.
Endocrine: Denies heat or cold intolerance. Excessive thirst and hunger is
improved. New-onset Type 2 DM.
Allergic/Immunologic: Denies allergies or immunologic disorders.
OBJECTIVE DATA:
Vital signs: Ht. - 64 inches, Wt. - 194lbs, BMI – 33.3, HR - 78, BP - 156/82, RR - 22,
Temp. - 97.6, oral, O2 sat - 99% on room air.
General: Alert, oriented, and appropriate. No acute distress noted. Appears well
nourished, and well groomed. Cooperative.
HEENT: Facial features are symmetrical. No facial tenderness. Wearing a wig reports its
for convenience. Unable to assess head for hair distribution or perform scalp’s assessment.
Denies abnormalities or injuries to head or hair. Sclera white and moist. Conjunctiva pink and
moist. PERRLA. Tympanic membranes are intact bilaterally, without bulging or drainage.SOAP NOTE: HYPERTENSION
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Mucous membranes moist, pink, and symmetrical. No halitosis presents. Good to fair oral
hygiene. with dark discoloration noted to dental chewing surfaces. Denies dental sensitivity. No
exudates or lesions noted to oral cavity. Nasal passages clear, no drainage or congestion. Nares
are patent bilaterally.
Neck: Midline and supple. No tracheal deviation noted. No swelling, stiffness, or pain
noted or palpated. No JVD, carotid bruits, or lymphadenopathy.
Chest/Lungs: Chest rises and falls symmetrical without audible congestion. Lungs clear
to auscultation. Chest is symmetrical.
Heart/Peripheral Vascular: S1 and S2 auscultated. No murmurs gallops or rubs present.
Apical pulse 72 and regular. Radial and pedal pulses palpated 2+ bilaterally. Capillary refill <
2secs. No edema presents.
Abdomen: Abdomen soft, non-tender, and non-distended. Bowel sounds active in all
quadrants. No masses noted or palpated. No rebound tenderness or guarding presents.
Genital/Rectal: Deferred.
Musculoskeletal: Moves all extremities with ease. Gait steady. No use of assistive
devices. Full active and passive ROM present. No joint stiffness nor deformities presents.
Strength and grip equal bilaterally. Rate 5/5 for ROM and strength in all extremities.
Neurological: CN II-XII grossly intact. Monofilament test to feet and toes, sensation
intact bilaterally. Fine and gross motor skills are intact. No deficits in balance or coordination
noted. DTR 2+ bilaterally.
Skin: Warm, dry, and intact without break in integrity. Color appropriate for race. Normal
hair distribution. No rashes, bruises, dryness, or discoloration noted.
Labs: CBC, CMP, lipid panel, A1C, and UA reviewed from previous visit.SOAP NOTE: HYPERTENSION
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CBC – WNL
Glucose (Fasting) – 163, A1C – 7.6, Total Chol – 192, HDL – 55, Triglycerides – 92, LDL – 129.
UA - negative
ASSESSMENT:
1. Hypertension: Blood pressure is the force in arterial structures created by an interplay of
flow, volume, and constriction; high blood pressure, or hypertension has been defined by
determining the levels of blood pressure that cause target organ damage, morbidity, and
mortality as arterial flow is delivered (Buttaro et al., 2017).
2. Type 2 Diabetes Mellitus: Type 1 and Type 2 diabetes share the features of
hyperglycemia and an increased risk for vascular and neuropathic complications;
hallmarks of Type 2 diabetes are insulin resistance and impaired beta cell function
(Buttaro et al., 2017).
Differential Diagnoses:
1. Obesity – Obesity is a common risk factor for both diabetes and hypertension;
obesity have common genetic factors that have a strong additive effect on the
development of hypertension (Shaik, 2017).
2. Stress – Stress links diabetes and hypertension, as a known CV risk factor; genetic
factors and environmental factors leads to diabetes and hypertension; form a vicious
cycle of hypertension and diabetes (Shaik, 2017).
3. Metabolic Syndrome – group of risk factors that raises your risk for heart disease
and other health problems, like hypertension and diabetes; metabolic risk factor sge
abdominal obesity, high triglyceride (or on medicine or treat triglycerides), low HDL
cholesterol level (or on medicine to treat low HDL cholesterol), high blood pressure
(or on medicine to treat high blood pressure), high fasting blood sugar (or on
medicine to treat high blood sugar) (nih.gov., 2017).
PLAN:SOAP NOTE: HYPERTENSION
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Treatment Plan:
1. Continue Lisinopril 10mg and Metformin 500mg. Angiotensin converting enzyme
inhibitors (ACEI)/angiotensin receptor blockers (ARBs) are the most effective drugs
for treating hypertension in diabetes, in the absence of contraindications (Shaikh,
2017).
2. Crestor 20mg nightly added to home medication. The American Diabetes Association
is recommending a less stringent diastolic blood pressure target for people with
diabetes and that all people with diabetes take either moderate or high doses statin
(diabetes.org. 2014).
3. Prescribed diabetic and blood pressure monitoring kit for home use and educate
patient on the proper use. Patient will monitor blood sugar (fasting) in the a.m. and at
bedtime for the next two weeks, record the reading and bring to the office. The patient
will do the same with blood pressure. The patient will also keep a dairy of dietary
intake and exercise regimen.
4. CBC, CMP, Lipid Panel, and TSH every six months and Hgb A1C every four months.
5. Schedule ophthalmology and depression screening per the company’s policy. People
with diabetes have a higher risk of blindness; regular checkups may prevent
blindness; depression in people with diabetes is much higher than the general
population; women experience depression about twice as often as men (diabetes.org.,
2017).
6. Follow-up in two weeks.
Health Promotion: The patient is educated on healthy living and becoming accountable
for her health. Before the patient is responsible for her health, she must be given the tools
to conquer the disorder successfully. The patient is educated on the acceptable range for
her blood pressure, blood sugar, A1C, and weight. Systolic BP <130 and diastolic BP <80SOAP NOTE: HYPERTENSION 8
may be appropriate for young patients with diabetes; HbA1c <5.7% (Shaikh, 2017). The patient is given guidelines and behavior changes to adopt for her numbers to reach the acceptable range. Along with adhering to the doctor’s orders, the patient must change her diet and increase exercising. Salt restriction, weight loss, avoiding smoking, and decreasing alcohol intake all play a part in the management of hypertension and diabetes (Shaikh, 2017). The patient should also be referred to a nutritionist and diabetes education. If that is not available, the patient is given websites that may have information to further her knowledge on adopting a healthier lifestyle for herself and her family. Nurses have a responsibility to encourage a healthy lifestyle when providing advice on managing obesity and diabetes (Bostock-Cox, 2017).
REFLECTION: I am very impressed with the knowledge of my preceptor, and at this junction, I agree with
her plan. The rural health program has limited resources, but she made every effort to prescribe a method that work best for the patient and her income. The preceptor was conscientious of her age, her young children, income, and social issues as she developed her treatment plan. She counseled the patient and commended the patient on her progress. I did not know about depression in diabetics, which was a topic brought to my attention by my preceptor and a problem that I researched. [Show Less]