Discussion Example of Acute Care Soaps Notes
HPI: 45 y/o female from the Virgin Islands admitted for infected left stump. Transferred to ICU for worsening septic shock with respiratory distress. Last night had active bleeding from stump, surgery at beside. Patient in cardiac arrest x2 with ROSC. 4 units PRBC, 2 FFP, 1 of platelets given.
> PMH: chronic- HTN, PVD, DM, Mitral regurgitation, MI, HFrEF 20-25% (8/17), pulmonary hypertension
> FH: Mother HTN, Father DM.
> SH: Denies use of alcohol, drugs or smoking.
> ALL: NKDA
> MEDS: Metformin 500 mg BID, Metoprolol succinate 100 mg PO daily, aspirin 81 mg PO daily
> VS: BP 97/55, HR 98, RR 20, MAP: 69, O2: 100%, Ht: 5’3”, Wt 89 kg, BMI 34.9
> LABS: AST 396/ ALT 63 ^, WBC 14.8 ^, H/H 7.6/30, platelets 350, aPTT 40, Glucose 202 ^, Na 144, K+ 3.9, lactic 10^. BUN 40, creat 3.0. Leg wounds culture: achromobacter. Tracheal aspirate: stenotrophomonas (9/9)
> PE: Anasarca. Mechanical ventilation, diminished breath sounds. Wet gangrene of leg stump debrided. Dry gangrene of right lower extremity. Lines: NG tube, PICC, left IJ.
> Assessment: 1. Septic shock 2. Acute Hypoxic respiratory failure 3. Left stump infection, dry gangrene of RLE 4. Post cardiac arrest 5. Apical thrombus
> Plan :
> 1. Septic shock. Continue vasopressors, levophed currently at 15 mcg/min. Analgesia with fentanyl drip, dilaudid 0.5 mg q4h PRN. Monitor CBC/BMP and lactic levels. Daptomycin to be continued for 6 weeks (from 8/25). Mondays check CKP, ESR, CRP levels while on daptomycin. GI prophylaxis with Pepcid 20 mg IV daily. Glucose checks q8h.
> 2. Acute hypoxic respiratory failure. Continue mechanical ventilation and monitoring of patient oxygenation. Fio2 successfully titrated from 60 to 40%.
> 3. Left stump infection, dry gangrene of RLE. Zosyn 3.375 IV to be continued for 6 weeks from 8/25. Consult ID.
> 4. Pending CT brain post cardiac arrest.
> 5. DVT prophylaxis with heparin drip (apical thrombus). Continue to monitor coagulation levels.
EVIDENCE-BASED PRACTICE FOR NURSES Appraisal and Application of Research
Evidence-Based Practice for Nurses: Appraisal and Application of Research, Third Edition, drives comprehension through various strategies that meet the learning needs of students, while also generating enthusiasm about the topic. This interactive approach addresses different learning styles, making this the ideal text to ensure mastery of key concepts. The pedagogical aids that appear in most
chapters include the following:
Chapter Objectives These objectives provide instructors and students with a snapshot of the key information they will encounter in each chapter. They serve as a checklist to help guide and focus study.
Found in a list at the beginning of each chapter and in bold within the chapter, these terms will create an expanded vocabulary in evidence-based practice.
Critical Thinking Exercises An integral part of the learning process, critical- thinking scenarios and questions are presented by the authors to spark insight into situations you may face in practice.
Quick tidbits and facts are pulled out in chapter margins to highlight important aspects of the chapter topic.
Test Your Knowledge
These questions serve as benchmarks for the knowledge you are acquiring as you move throughout the chapter.
Rapid Review This succinct list at the end of the chapter compiles the most pertinent and key information for quick review and later reference.
Apply What You Have Learned
With this outstanding feature, you will be challenged to apply your newly acquired knowledge to specific evidence-based practice scenarios and research studies.
Case Examples Found in select chapters, these vignettes illustrate research questions and studies in actual clinical settings and provide critical-thinking challenges for students.
Keeping It Ethical
Relevant ethical content concludes each chapter to ensure ethics are kept at the forefront of every step of the nursing process.
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