Provide a SOAP nursing note, Patient teaching to include…

Question Answered step-by-step Provide a SOAP nursing note, Patient teaching to include… Provide a SOAP nursing note, Patient teaching to include anticipatory guidance for the child, medication teaching and teaching regarding when to bring child to ED?Keith RobertsKeith Roberts, age 3 months, is seen in the well child clinic. His mother describes feeding as difficult since Keith tires easily. He has not gained weight as expected and his mother expresses doubts about her parenting ability. Her pregnancy was difficult and she finds it stressful to care for her first baby who is not thriving. The nurse recognizes that fatigue during feeding and failure to gain weight are characteristic signs of heart disease in infants. The clinic nurse conducts a comprehensive physical assessment of Keith. During the physical assessment, Mrs. Roberts expressed doubt about her mothering ability. She is upset about Keith’s “scrawny and weakling” appearance. She expresses fear of hurting the baby and fears that his illness is her fault. She appears drained and tired. On physical assessment, Keith is found to have a cardiac murmur and signs of heart failure. He is referred to the children’s hospital for diagnosis of a probable congenital heart defect. Keith is scheduled for chest x-rays (which show prominent pulmonary arteries), blood gas analysis, and a cardiac catheterization. After talking with the cardiologists, the parents ask the nurse for more information about the cardiac catheterization. There is an order to administer oxygen to Keith via nasal cannula. Cardiac catheterization indicates that Keith has a large ventricular septal defect (VSD) with pulmonary vascular resistance. The HCP communicates the results to the Roberts as well as the diagnosis of heart failure. The parents are confused and they ask the nurse for more information. Despite explaining VSD, the repair, and encouraging questions and answers, Mrs. Roberts breaks down crying. She states her baby is going to die. The nurse gently probes her understanding and learns that Mrs. Roberts’ concept of heart failure means that Keith is at risk for sudden death. Digoxin is an inotropic drug that increases the strength of the cardiac contraction. Captopril is an angio-tension inhibitor that reduces afterload on the heart. Medical management is initiated to improve Keith’s cardiac output. Prescriptions include administration of oral digoxin (Lanoxin). Keith’s hypercyanotic spell indicates the need for immediate surgery. He will undergo bypass surgery with closure of the septal defect with a Dacron patch and pulmonary banding. Keith returns to the Pediatric Intensive Care Unit (PICU) following cardiac bypass surgery with closure of the septal defect and pulmonary banding. The nurse prioritizes careful monitoring. Keith recovers from surgery and is transferred to the acute care unit. Mrs. Roberts is increasingly involved in his care. Keith recovers from surgery without complications. His parents’ confidence in parenting skills increased with supportive nursing guidance. Keith begins to gain weight and the Roberts learned to promote age-appropriate development. They demonstrate competence in medication administration and follow guidelines for follow up. Health Science Science Nursing VNRS MISC Share QuestionEmailCopy link Comments (0)