Making a soap note for this scenario

Assignment Help Other Subject

Reference no: EM133297274

Question: MAKING A SOAP NOTE FOR THIS SCENARIO

Your patient Mrs. Peacock, age 63, presents with a fever, chills, productive cough with thick yellow secretions. Mrs. Peacock smoked a pack and a half a day from the time she was 18 until two years ago when she quit. Presenting at the ER on room air, her HR is 114, temp 102 F, respiratory rate 27 and labored/shallow. Her SpO2 via finger probe is reading 85% with a good waveform/pleth. ABG reveals: pH 7.31, PaCO2 59, PaO2 55, HCO3 32, BE + 10. She is using her accessory muscles for breathing and pursing her lips on exhalation. She is leaning over on the table with her elbows propping her torso up.

She has an increased tactile fremitus. Breath sounds are diminished bilaterally at the bases with soft expiratory wheezes bilaterally throughout. She also has faint course crackles on the right side. Her percussion note is flat on the right lower lobe and hyper resonant in all other lung fields.

She seems to have a barrel chest and is cyanotic looking with JVD, and edema in her hands and feet. This is the second year in a row that she has had to come to the ER with these same symptoms.

Reference no: EM133297274

Questions Cloud

What are some downsides of the case : What benefits, if any, did Southwest get by making the following choices? What, if any, were some concerns or downsides with the above actions?

What are cultural considerations for patients : NUR 230 Nursing College What are the necessary communication and/or teaching needs for the patient and/or family regarding status epilepticus.

What are the medical management of patients : What are the necessary communication and/or teaching needs for the patient and/or family regarding increased intracranial pressure

What kinds of discrimination exist in your industry : What kinds of discrimination exist in your industry?How does this discrimination manifest itself?In what aspects and levels of the industry is it most prevalent

Making a soap note for this scenario : MAKING A SOAP NOTE FOR THIS SCENARIO This is the second year in a row that she has had to come to the ER with these same symptoms

What kind of questions do you think cincinnati office shows : What kind of questions do you think Cincinnati office shows as graders owners before agreeing to lone the company $10 million why would graders go

Describe one competency where you have an opportunity : NUR 612 Chamberlain College of Nursing Describe one competency where you have an opportunity for continued enhancement in the weeks ahead. What steps can you

What are the solutions given by the researchers for worklife : What are the solutions given by the researchers?Where do you really find a problem?What is the solution for Problems of work life balance

Research a health care organization or network : NRS 451-0501 Grand Canyon University Research a health care organization or network that spans several states with in the United States (United Healthcare)

User Account

All Pages