Physical Assessment Nursing SOAP Patients with Hypertension Case Study
You will perform a history of a nose, mouth, throat, or neck problem that your instructor has provided you or one that you have experienced, and you will perform an assessment including nose, mouth, throat, and neck. You will document your subjective and objective findings, identify actual or potential risks.
USE Soap Notes format.
Subjective: (S)
History of Illness:
Chief Complaint:
History:
Review of Systems:
Objective: (O)
Physical Assessment data (Assessment-A)
Plan
Use this case study don’t make up your own, please
History and Physical:
Anthony Lewis is a 48 year old male with a history of hypertension. Anthony came into the ER presenting with swollen lips. This angioedema was determined to be due to recently starting Lisinopril, last week. Anthonys blood pressure was 210/90 upon arrival to the ER. He received 10 mg Hydralazine, and his blood pressure decreased to 150/40. The house physician ordered hydrochlorothiazide, and discontinued Anthonys Lisinopril.
Nursing Note:
Anthony was admitted to the medical/surgical floor at 0500, on the night shift. The MD admitted him for airway monitoring, and hypertension management. You are the day shift receiving report from the night nurse.
Patient Blood pressure last night 210/90 in ER. report: The patient received hydrochlorothiazide 25 mg PO last night, and is to receive this in the morning. Lets take the blood pressure and vitals now as part of our handoff.
Provider Orders:
- Labs obtained in the ED include CBC, CMP
- ECG
- Urinalysis
- Labs in AM include Lipid Panel and HbA1c
- Renal U/S
- NPO (except medications)
- Initiate Saline lock
- Oxygen to maintain SpO2 greater than 94%
Activity as tolerated
In your HEENT assessment, focus on airway, how would you assess if obstructed?
