Posted: May 1st, 2022

SOAP Note: My wife seems to be having trouble hearing me when I talk

Assets wanted on some questions and week four task

Kennedy-Malone, L., Martin-Plank, L., & Duffy, E. (2019). Head, neck, and face problems. In Superior observe nursing within the care of older adults (2nd ed., pp. 127–151). F. A. Davis.

Goldberg, C. (2018b). The attention examination. In C. Goldberg, Sensible information to medical medication. Regents of the College of California. https://meded.ucsd.edu/clinicalmed/eyes.htm

Required Media (click on to broaden/scale back)

Medical doctors in Coaching [doctorsintraining]. (2016, October 18). PANCE and PANRE overview course pattern video—eye problems half 1 [Video]. YouTube. https://youtu.be/lALqptCrPrs

Advisable Media (click on to broaden/scale back)

Have interaction-IL (Producer). (2017p). Vitamin for the older grownup [Video]. https://engageil.com/modules/nutrition-for-the-older-adult/

Word: View the Vitamin for the Older Grownup video module obtainable on this free course.

Have interaction-IL (Producer). (2017q). The older grownup with visible, hearing, and cognitive impairment [Video]. https://engageil.com/modules/the-older-adult-with-visual-hearing-and-cognitive-impairment/

Word: View The Older Grownup with Visible, Hearing, and Cognitive Impairment video module obtainable on this free course.

Have interaction-IL (Producer). (2017s). Oral well being and the older grownup [Video]. https://engageil.com/modules/oral-health-and-the-older-adult/

Word: View the Oral Well being and the Older Grownup video module obtainable on this free course.

Task: Assessing, Diagnosing, and Treating Head, Neck, and Face Problems

Picture Credit score: Getty Pictures/Mix Pictures
Head, neck, and face problems are frequent, and thus you’ll doubtless take care of aged sufferers with these problems. In your function as a sophisticated observe nurse, you need to be in a position not solely to appropriately assess and diagnose sufferers but additionally Help sufferers handle the dysfunction by planning needed therapies, assessments, and follow-up care.
To arrange:
• Evaluate the case research offered by your Teacher.
• Replicate on the affected person’s signs and facets of problems that will be current.
• Think about the way you may assess, carry out diagnostic exams, and advocate medicines to deal with sufferers presenting with the signs within the case.
• Entry the Targeted SOAP Word Template on this week’s Assets.

Directions :
The Task:
Full the Targeted SOAP Word Template offered for the affected person within the case research. Be certain to deal with the next:
• Subjective: What was the affected person’s subjective criticism? What particulars did the affected person present concerning their historical past of current sickness and private and medical historical past? Embrace an inventory of prescription and over-the-counter medicine the affected person is at the moment taking. Examine this record to the American Geriatrics Society Beers Standards®, and take into account different medicine if applicable. Present a overview of methods.
• Goal: What observations did you be aware from the bodily Assessment? What have been the lab, imaging, or purposeful assessments outcomes?
• Assessment: Present a minimal of three differential diagnoses. Checklist them from high precedence to least precedence. Examine the diagnostic standards for every, and clarify what guidelines every differential in or out. Clarify you vital considering course of that led you to the first analysis you chose. Embrace pertinent positives and pertinent negatives for the particular affected person case.
• Plan: Present an in depth remedy plan for the affected person that addresses every analysis, as relevant. Embrace documentation of diagnostic research that may be obtained, referrals to different health-care suppliers, therapeutic interventions, training, disposition of the affected person, caregiver Help, and any deliberate follow-up visits. Present a dialogue of well being promotion and illness prevention for the affected person, taking into account affected person components, previous medical historical past (PMH), and different danger components. Lastly, embrace a mirrored image assertion on the case that describes insights or classes discovered.
• Present at the least three evidence-based peer-reviewed journal articles or evidenced-based pointers, which relate to this case to Help your diagnostics and differentials diagnoses. Be certain they’re present (not more than 5 years outdated) and Help the remedy plan in following present requirements of care. Comply with APA seventh version formatting.

NOTE!!!!!!!
6540 NRNP Week four Begins Dec. 20 – Head, Neck, and Face Problems
IMPORTANT FEEDBACK:
Please full the required readings and media, use these in your references as applicable.
Please overview the Rubric offered in BB.
Submit within the Originality report part.
Only a reminder that you’re accountable to learn all of the required readings for the week in BB, all the knowledge & rubrics, in addition to the entire suggestions that I provide you with. The knowledge that I offered included that cleaning soap notes are digital: that means that as the scholar you fill in any lacking or pertinent data that you simply really feel is essential to the case (YES, you’re ‘filling within the blanks” Use your expertise with previous sufferers to do that).
This would come with VS (if not given) – you may select a weight, and you have to to calculate the BMI – which is simple to do in your telephone, ROS, PE, FH, SH, and so forth. You additionally want to present a paragraph for diagnostics and lab outcomes ( as an NP these are put on the finish of the PE, not interspersed within the ROS or PE). It is a main distinction between a nursing be aware and a medical be aware. I will take factors off if there are lab leads to the ROS or PE.

CHOICE CASE STUDY:
PLEASE CHOOSE ONE OF THE CASES BELOW FOR YOUR SOAP NOTE:
Week four Case 1
A 76-year-old lady presents in the present day with complaints of nasal drainage, clearing of throat, and occasional nasal congestion, particularly on waking within the morning. She has just lately moved into an unbiased dwelling middle after dwelling in her residence for 40 years. She states that, though she has had these signs earlier than, usually the signs appeared within the spring, and he or she related the nasal drainage with pollination. As a result of it’s winter, she couldn’t establish the set off of her signs.
Chief criticism: Persistent “runny nostril” for Three-week length, related clearing of throat, and nasal congestion on awakening within the morning.
Goal knowledge: Blood strain (BP) 130/84, temperature 98.6, pulse 78, respiratory fee 20. WT:___ BMI:____

What additional ROS questions will you need to ask her? Checklist at the least three.

What bodily examination (PE) will you carry out on this affected person? Checklist at the least three.

What are the differential diagnoses that you’re contemplating? Describe at the least 4.

What laboratory exams will enable you rule out a number of the differential diagnoses?

You’ve decided, by selecting your ROS, PE, and differential analysis, that this affected person has allergic rhinitis (AR). Describe the remedy choices to your analysis, and what particular details about the prescription will you give to this affected person? Checklist at the least two remedy choices: medicines with dose, unwanted side effects and/or cautions within the older grownup.
When will you might have the affected person comply with up? Be particular.

Write a targeted SOAP be aware for this case. Select the ROS, PE, and medicines you’ll use in your SOAP be aware.

Week four Case 2
CC: My wife seems to be having trouble hearing me when I talk. She is popping the TV up loud.
HPI: Mary is an 88-year-old African American (AA) feminine married for 50 years to Albert. Albert complains that Mary can’t hear or hears however doesn’t perceive (particularly in a gaggle); turns up radio or tv louder to hear (additionally famous by household, buddies, and neighbors); Mary complains of tinnitus; and he or she appears like persons are “mumbling.”
PMH: Mary takes ramipril for hypertension (HTN), a child aspirin for cardio safety, and a statin for hypercholesterolemia.
Important indicators are 120/88 P: 88 P02: 96% WT: 156 HT: 5’6” BMI:_____
ROS: Ask if Mary has had any publicity to ototoxic medicine or different otic harm previously. Describe at the least three.
PE: What examinations will you carry out on the ear? Describe the areas of the ear you’ll consider and what you’ll anticipate to discover.

Diagnostic Testing: Please describe at the least three (Three) strategies to check for hearing.
You establish that Mary has a hearing deficit and tinnitus. What differential diagnoses would you like to take into account? Describe at the least three.
What is going to your remedy plan for this affected person be?
What different suggestions will you make (i.e., screening)?
What referrals will you make?
Schooling: Title at the least two issues you’ll educate your affected person about concerning their hearing.
Select the ROS, PE, and DD and closing analysis for this affected person, after which write up your targeted SOAP be aware.

Targeted SOAP Word

Scholar’s Title
Institutional Affiliation
Course
Professor’s Title
Date

Targeted SOAP Word
Affected person Info:
M, 88, F, AA
S (subjective)
CC (chief criticism): My wife seems to be having trouble hearing me when I talk. She is popping the TV up loud.
HPI (historical past of current sickness): Mary is an 88-year-old African American (AA) feminine married for 50 years to Albert. Albert complains that Mary can’t hear or hears however doesn’t perceive (particularly in a gaggle); turns up radio or tv louder to hear (additionally famous by household, buddies, and neighbors); Mary complains of tinnitus; and he or she appears like persons are “mumbling.”
Present Drugs:
Ramipril
Child aspirin
Statin
Allergic reactions: No identified drug or meals allergic reactions.
PMHx: Mary takes ramipril for hypertension (HTN), a child aspirin for cardio safety, and a statin for hypercholesterolemia.

Soc and Substance Hx: Lives with the husband Albert who complains the wife can’t hear tv or radio and he or she want to improve the amount. No historical past of drug and alcohol abuse.

Fam Hx: Sicknesses with doable genetic predisposition, contagious, or persistent diseases. Purpose for loss of life of any deceased first-degree relations ought to be included. Embrace mother and father, grandparents, siblings, and youngsters. Embrace grandchildren if pertinent.
Surgical Hx: Prior surgical procedures.
Psychological Hx: No historical past of despair, anxiousness, or suicidal ideation.
Violence Hx: No historical past of bodily violence at residence or within the neighborhood. No historical past of sexual violence.
Reproductive Hx: The 88-year-old affected person is above reproductive age. Her final menstrual date shouldn’t be identified. She is married however it’s not clear if she is sexually energetic.
ROS (overview of signs):
GENERAL: No unintentional weight lack of achieve, fatigue, fever, chills, and physique weak spot.
HEENT:
• Eyes: No visible loss, double imaginative and prescient, or blurred imaginative and prescient.
• Ears, Nostril, Throat: No hearing loss, nasal congestion, or sore throat.
SKIN: No itching, bruises, or lesions.
CARDIOVASCULAR: No chest ache, discomfort, edema, or chest strain.
RESPIRATORY: No coughing, sputum, or shortness of breath.
GASTROINTESTINAL: No nausea, diarrhea, or vomiting. No stomach ache or blood within the stool.
GENITOURINARY: No burning sensation on urination. Final menstrual interval date is unknown.
NEUROLOGICAL: No dizziness, tingling within the extremities, or headache. No modifications in bowel or bladder management.
MUSCULOSKELETAL: No joint or muscle ache, or stiffness.
HEMATOLOGIC: No bleeding, bruising, or indicators of anemia.
LYMPHATICS: No historical past of splenectomy or enlarged nodes.
PSYCHIATRIC: No historical past of mania, despair, or anxiousness.
ENDOCRINOLOGIC: No historical past of sweating, polyuria or polydipsia.
REPRODUCTIVE: No historical past of current being pregnant, vaginal discharge or sexual activity.
ALLERGIES: No historical past rhinitis, hives, or eczema.
O (goal)
Bodily examination:
120/88 P: 88 P02: 96% WT: 156 HT: 5’6”
Diagnostic outcomes:
Otoscopy- examination of exterior ear, wax within the ear can be simply visualized.
Rinne’s check to verify hearing loss
Weber’s check – these are exams to discover out kind of hearing loss primarily based on medical examination.
Pure tone audiometry- I may also get affected person’s audiometry executed.
Visualization of ear by x-ray, CT scan to assess for any blockage.
A (Assessment)
Differential diagnoses:
Wax within the ear – largely causes conductive deafness. Tinnitus might or might not be current. Ear wax is generally secreted to defend the ear and it naturally cleanses itself. Accumulation of an excessive amount of wax can have an effect on the ear inflicting hearing problem (Di Stadio et al., 2018). Wax within the ear is the commonest reason for conductive hearing loss.
Meniere’s disease- deafness, tinnitus, and vertigo is current. The situation causes a ringing sound within the ear. It makes people expertise hearing problem (Hannigan et al., 2019). A number of the causes of the situation embrace stress, fatigue, emotional misery, strain modifications, and different well being issues.
Cerebellopontine angle tumor- these tumors additionally current with deafness and tinnitus. The most typical situation is vestibular schwannoma. One of many frequent signs is the sudden lack of hearing capability. The expansion might trigger strain on the ear nerves main to hearing loss.
Otosclerosis – the affected person may be susceptible to otosclerosis. Extra diagnostic exams are needed to avert well being issues (Mkrtchyan et al., 2021). The situation entails the lack of the bone to vibrate to permit the ear to detect sounds.
P (plan)
The affected person ought to begin the treatment to combat the bacterial an infection that may trigger hearing loss. Gentamicin 10ml BID is efficient to clear the ear for hearing loss issues.
Amikacin 250 mg/ml is an antibacterial used to deal with infections that may trigger hearing loss. The affected person ought to be noticed due to unwanted side effects resembling diarrhea, dizziness, and numbness (Mkrtchyan et al., 2021).
Streptomycin is efficient for the remedy of hearing loss because it causes much less ototoxicity in contrast to different medicine.
A practitioner will perform a bodily examination to decide if the wax within the ear is inflicting hearing loss (Weiss et al., 2020). The remedy will embrace eradicating the wax and checking if the affected person can enhance on the hearing means.
Reflection.
I discovered that totally different causes of hearing loss can have an effect on sufferers at totally different ages. I discovered that efficient analysis and remedy of hearing loss is efficient for restoration. The restoration would require follow-up to guarantee enchancment (Weiss et al., 2020). I discovered that sufferers can expertise hearing loss due to outdated age. Applicable analysis and remedy are efficient for restoration.
The affected person ought to adhere to the remedy and are available again to the clinic for 2 weeks. The husband ought to make sure the wife is taking the treatment and monitor the advance. In case the affected person doesn’t enhance, a CT scan may be needed to look at the reason for the hearing loss.
In the course of the remedy, it’s efficient to present data to the affected person to acquire knowledgeable consent. The affected person ought to obtain remedy with out discrimination. Justice is a core worth within the administration of care (McDermott-Levy et al., 2018). Veracity entails telling the affected person the reality to guarantee they find out about their sickness and applicable remedy. The affected person ought to be knowledgeable concerning the danger components of hearing loss and the unwanted side effects of the treatment (McDermott-Levy et al., 2018).
In the course of the remedy, it is important to look at the danger components that may trigger hearing loss. Aged sufferers with diabetes or hypertension are susceptible to hearing loss. A coronary heart situation, stroke, or mind harm can lead to hearing loss (Di Stadio et al., 2018). Collaboration with different healthcare employees is efficient within the restoration of the affected person.
The affected person ought to keep away from danger components that may trigger antagonistic well being outcomes. As an example, loud noises resembling tv or radio can have an effect on the affected person. The affected person ought to keep away from publicity to mud which may have an effect on the affected person or trigger accumulation of wax.
The affected person ought to adhere to remedy and are available again for analysis after two weeks.

References
Di Stadio, A., Dipietro, L., Ricci, G., Della Volpe, A., Minni, A., Greco, A., … & Ralli, M. (2018). Hearing loss, tinnitus, hyperacusis, and diplacusis in skilled musicians: A scientific overview. Worldwide journal of environmental analysis and public well being, 15(10), 2120.
Hannigan, I. P., Welgampola, M. S., & Watson, S. R. (2019). Dissociation of caloric and head impulse exams: a marker of Meniere’s illness. Journal of Neurology, 1-9.
McDermott-Levy, R., Leffers, J., & Mayaka, J. (2018). Moral ideas and pointers of worldwide well being nursing observe. Nursing outlook, 66(5), 473-481.
Mkrtchyan, N., Alciato, L., Kalamarides, M., Bernardeschi, D., Sterkers, O., Bernat, I., … & Lahlou, G. (2021). Hearing restoration after surgical resection of non-vestibular schwannoma cerebellopontine angle tumors. European Archives of Oto-Rhino-Laryngology, 1-10.
Weiss, R., Loth, A., Leinung, M., Balster, S., Hirth, D., Stöver, T., … & Kramer, S. (2020). A brand new adhesive bone conduction hearing system as a remedy possibility for transient hearing loss after center ear surgical procedure. European Archives of Oto-rhino-laryngology, 277(Three), 751-759.

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