Hi I need help making a soap note about a chronic condition, the…

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Question Answered step-by-step Hi I need help making a soap note about a chronic condition, the… Hi I need help making a soap note about a chronic condition, the patient can be made up CRITERIA:The clinical reflection note will be based on a patient with a CHRONIC health condition. This note will be submitted in SOAP note format with HPI, HX, ROS, PE, Differential Diagnoses, Diagnostics, Diagnosis, Plan, ICD-10 codes and CPT codes. Health Science Science Nursing NRS 471 Share QuestionEmailCopy link Comments (0)

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Question LUCY WINTERSLucy is 17-year-old Hispanic female, G2 P0, 41 weeks' gestation. She is a patient of Dr Jay, for induction of labor.History: Lucy reports her blood pressure was high last her last doctor's appointment. She denies any health problems except anxiety which she is on medication for. Lucy, report she has had her wisdom teeth removed. She denies smoking, using alcohol, or illicit drugs. She has had her Tdap, Covid, & varicella vaccine. Lucy is 5' 1" & weight is 172 lb. Lucy has NKDA. She has not been sick or had any symptoms of COVID for the last 4 weeks. Lucy reports she not fallen in the last 6 months. Lucy reports she plans on laboring without medication and having natural delivery since her mother and sister had natural labor & delivery. She is unmarried she has an on again off again relationship with the father of the baby. She lives with her parents currently. She is a sophomore at a local alternative school. She works part time at a Costco for minimum wage. Lucy is currently taking sertraline 100mg po daily, Prenatal vitamins po daily, slow Fe one tablet daily.Prenatal labs:Type & Rh          A negativeAntibodies          negativeHepatis B            NegativeHIV 1st & 3rd             Negative                      RPR                      NonreactiveRubella               ImmuneGonorrhea         NegativeChlamydia          NegativeGBS                      Positive  Physical Assessment:     fill in the blank; all systems are normalReproductive:Leopold's performed:     give normal findingsFHT:                                   Reactive NSTFHT:                                   Fill in the blanks; Category I strip Baseline; FHT normal baseline for fetus at 41 weeks                                           Variability;                                           Acceleration or Deceleration;Uterine activity:               Frequency; Use normal findings for Phase I of Labor                                           Duration:                                           Intensity:Labor: FHT:                                  Fill in the blanks; Category II strip Baseline; FHT normal baseline for fetus at 41 weeks                                           Variability;                                           Acceleration or Deceleration; after 6 cm patient is experiencing recurrent late decelerationsUterine activity:               Frequency; Use normal findings for Phase 2 & 3, of Labor                                           Duration:                                           Intensity:  Physician Orders: Fetal monitoring continuous.     NST prior to inductionReport any Category II or III stripClear liquidsLabs: CBC, RPR, Hep B, VDRL, Type & Rh, COVID nasopharyngeal swabVS q 15 minutes when on pitocin q 3 minutes after epidural x 30 minutesTemp q 2hours after AROM/SROMPt may have an epidural after 3cm Medications:Start IV with LR. Bolus with 500ml of fluid prior to starting of Pitocin, Category II or III FHT strips. Give fluid bolus 1000ml-1500ml prior to epiduralLidocaine 1% for infiltrate for IV.LR 500ml with 30u Oxytocin: start induction at 2mu/min and increase q15-30 minutes. Maximum dose is 30mu/min.Butorphanol 1-2mg IVP q1-2 hoursOndansetron 4mg IVP q 4 hours Nausea/VomitingEphedrine 5-10mg for drops in maternal BP    Health Science Science Nursing Share QuestionEmailCopy link Comments (0)
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