Advanced Nurse Practice in Reproductive Health Care
Advanced Nurse Practice in Reproductive Health Care
Episodic/Targeted SOAP Word
Affected person Data:
E.W., 69, Male.
S.
CC (chief criticism): I can’t hear a lot of the dialogue on the tv
HPI: E.W. is a 69-year-old male affected person who presents to the well being clinic complaining of problem in listening to a lot of the dialogue on the tv. One of many members of the family who accompany him to the ability complains the affected person can’t hear. He continues to work in the varsity setting. His medical historical past is sort of benign. His solely medicines are aspirin 81 mg. each day, a multivitamin each day, and occasional ibuprofen for again ache. Speech is obvious and coherent however tangential at instances. He makes no uncommon motor actions and demonstrates no tics. He denies any visible or auditory hallucinations.
Present Drugs:
Aspirin 81 mg. each day
Multivitamin each day
Occasional Ibuprofen
Allergy symptoms: NKDA
PMHx: Cerumen impactions faraway from each ears and again ache. Immunization data are updated.
Soc & Substance Hx: The affected person has no historical past of substance and alcohol abuse. He’s married however not sexually energetic. He lives along with his daughter and his spouse. He has labored in the printing firm for 35 years. He continues to work in college settings.
Fam Hx: The affected person is heterosexual however not sexually energetic. He’s married to 1 spouse they usually have a daughter. The spouse and the daughter haven’t any important medical historical past. The grandparents are deceased for no important medical historical past. The couple has no grandchildren.
Surgical Hx: No prior surgical procedures.
Psychological Hx: The affected person has no important psychological historical past, dizziness, tinnitus, or vertigo. The affected person has no historical past of despair, anxiousness, self-harm, or suicidal ideation.
Violence Hx: He has no historical past of bodily or sexual violence at dwelling, at work, or in the neighborhood.
Reproductive Hx: His reproductive system is wholesome however he’s at present not sexually energetic. He’s a father to 1.
ROS:
GENERAL: No unintentional weight reduction or achieve, fever, and fatigue.
HEENT: Eyes: No blurred imaginative and prescient or yellow sclera. Ears, Nostril, Throat: No listening to problem, nasal congestion, working nostril, or sore throat.
SKIN: No itching, pores and skin rashes, or lesions.
CARDIOVASCULAR: The affected person has no chest strain, edema, discomfort, ache, or palpitations.
RESPIRATORY: No respiration difficulties, sputum, or congestion.
GASTROINTESTINAL: No diarrhea, nausea, consuming issues, blood in the stool.
GENITOURINARY: No issues, ache, or inconsistencies in urination. No historical past of urinary system sickness.
NEUROLOGICAL: No adjustments in bowel, bladder management, dizziness, or ataxia. The affected person has no persistent headache or numbness.
MUSCULOSKELETAL: No ache in the muscle tissue, joints, stiffness, and again.
HEMATOLOGIC: No instances of bleeding or bruising.
LYMPHATICS: The affected person has no historical past of splenectomy. No swollen nodes.
PSYCHIATRIC: The affected person has a historical past of trauma, anxiousness, stress, or despair. He was handled for dementia for 2 years however didn’t take all of the medicines or adhere to the counseling tips.
ENDOCRINOLOGIC: The affected person has no historical past of polyuria, polydipsia, head, or sweat intolerance.
REPRODUCTIVE: The affected person isn’t sexually energetic. He has been in a heterosexual marriage. No ache in the reproductive organs, or penile discharge.
ALLERGIES: No recognized historical past of medication, climate adjustments, bronchial asthma, rhinitis, or eczema.
O.
Bodily examination:
Important Indicators: 118/80 P: 88 P02: 97% WT: 148 HT: 5’7”
Normal: A&O * four, appears to be like sick because of the boring face. The affected person is groomed for the clinic go to. He’s neat and hygienic and acutely aware of the encircling.
HEENT: Eyes: watery eyes. No problem in imaginative and prescient. Ears: No listening to problem throughout the dialog, the tympanic membrane is in place. Nostril: No itchy or congested nostril. Throat: No swollen tonsils.
Neck: JVD, full ROM, carotid no bruit.
Chest/Lungs: CTA AP&L, no dyspnea.
Coronary heart/Peripheral Vascular: The examination reveals no murmur or peripheral pulses +2 bilaterally, RRR, or edema.
Stomach: No irregular bowel sounds.
Genital/Rectal: Deferred.
Musculoskeletal: No irregular growth or asymmetrical motion. Energy 5/5.
Neurological: DTR intact, CN II – XII intact.
Pores and skin: No pores and skin lesions, rashes, blisters, and plaques.
Diagnostic outcomes:
CXR— no important cardiopulmonary findings.
MMSE—Ms. Washington scores 18 out of 30 with main deficits in orientation, registration, consideration and calculation, and recall. The rating suggests reasonable dementia.
A.
Differential Diagnoses
Dementia – dementia is the final time period for situations that result in lack of reminiscence. The prognosis of dementia is because of the MMSE rating of the affected person. The rating reveals the affected person has 18 out of 30. The affected person could possibly be experiencing dementia that has varied signs together with restricted social expertise, forgetfulness, and restricted pondering capabilities that intrude with each day actions (Janelidze et al., 2020).
Alzheimer’s illness – Alzheimer’s illness is a progressive illness that results in reminiscence loss. The situation happens when the cell connectors die thus undermining the reminiscence capabilities (Bron et al., 2017). The situation can result in confusion.
PTSD – Put up-traumatic stress dysfunction is a situation that causes traumatic recollections and experiences. The situation is widespread amongst individuals who have recollections of traumatic occasions (Bron et al., 2017). The trauma impacts the standard of life and participation in each day actions.
P.
The therapeutic interventions for dementia embody cholinesterase inhibitors reminiscent of Aricept. The aim of the drug is to enhance the chemical concerned in the reminiscence and judgment capabilities in the mind. Aricept 10mg tab bedtime is efficient (Nordström & Nordström, 2018). The affected person ought to go to the ability after two weeks for additional analysis. Psychotherapy is one other intervention for the therapy of the situation (Nordström & Nordström, 2018). The affected person must be referred to a counselor for added interventions.
The pattern of dementia and different psychological situations are widespread amongst aged sufferers. One of many necessary classes is to make use of each pharmacological and psychotherapeutic interventions to deal with the signs. One of the best affected person training is to encourage adherence to the therapy.
References
Bron, E. E., Smits, M., Papma, J. M., Steketee, R. M., Meijboom, R., De Groot, M., … & Klein, S. (2017). Multiparametric computer-aided differential prognosis of Alzheimer’s illness and frontotemporal dementia utilizing structural and superior MRI. European radiology, 27(eight), 3372-3382.
Janelidze, S., Mattsson, N., Palmqvist, S., Smith, R., Seashore, T. G., Serrano, G. E., … & Blennow, Ok. (2020). Plasma P-tau181 in Alzheimer’s illness: relationship to different biomarkers, differential prognosis, neuropathology and longitudinal development to Alzheimer’s dementia. Nature Medication, 26(three), 379-386.
Nordström, A., & Nordström, P. (2018). Traumatic mind damage and the chance of dementia prognosis: A nationwide cohort examine. PLoS drugs, 15(1), e1002496.
