Get Answer: Provide Soap Nursing Question Guide
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Original Question
Provide SOAP nursing note. Must include patient education and medication adherence. Include IV fluids and indicate what type of solution is being used and the rationale. Meet the Client: Donna King is an 80-year-old female with coronary artery disease and hypertension. Her daughter brought her to the Emergency Department because she has become increasingly weak and confused and was found by a neighbor wandering her neighborhood unable to locate her home. Donna’s daughter tells the nurse that her mother takes a “water pill” for her blood pressure 2 or 3 times a day. The label on the medication bottle that she brought to the hospital states, “hydrochlorothiazide (HydroDIURIL). Take 1 tablet daily.” Donna is admitted with fluid volume deficit. The nurse continues to assess the client and observes that Courtney’s skin tents when a fold of skin over her sternum is pinched. Math Donna’s daughter reports that her mother usually weighs about 137 lbs. and is 5 feet, 3 inches in height. The nurse weighs Donna and obtains a measurement of 60 kg. The nurse discusses factors that contributed to Donna’s fluid volume deficit with Donna and her daughter. The nurse is aware that the elderly often experience an increase in the amount of free, unbound drug molecules, which has the potential to increase the pharmacological effects of the drug. The nurse starts an intravenous line to administer fluids. The prescription states, “3% Normal Saline to infuse at 100 mL/hour.” The client’s most recent serum sodium level is 135 mEq/L. Medication Errors A short while later, a prescription for 0.9% Normal Saline at 100 mL/hour is received. Donna’s primary nurse is at lunch, so another nurse hangs the solution. When checking Donna upon returning from lunch, the primary nurse observes that a solution of 5% Dextrose and 0.9% Normal Saline is infusing at 125 mL/hour. Legal Consideration: Treatment ErrorAfter hanging the correct IV solution at the correct rate of infusion, the nurse discusses the error with the nurse who hung the first IV solution. Together, the nurses complete a variance (incident) report. The nurse who made the errors is very upset about writing a variance (incident) report and states, “I’ve never made an error before. What if I get fired?”. Local IV Site Complications Later that day, Donna’s IV pump alarm sounds. The nurse notes that the IV is not infusing in the right antecubital area, and the alarm indicates an obstruction is present. The nurse determines that all the clamps are open and there are no kinks in the tubing. The nurse resolves the obstruction, and the IV solution begins to infuse. The next day the nurse observes that the IV insertion site is inflamed and tender. The label on the IV site indicates the current IV has been in place for 36 hours. The nurse used the nursing process in deciding to remove Donna’s IV and restart it in a new location. Intake and Output Measurement Donna continues to receive 0.9% Normal Saline at a rate of 100 ml/hour. She is stronger and has started taking oral food and fluids well. She receives a regular no-added-salt diet. Her breakfast includes one cup of scrambled eggs, one bowl of oatmeal, a fresh orange, apple juice, and a carton of milk. When Donna was first admitted, the healthcare provider did not include intake and output measurement in the initial prescriptions, but the primary nurse initiated this assessment activity. Fluid Volume Excess Donna’s intake and output measurements indicate her intake is greater than her output. The nurse is concerned that Donna may develop fluid volume excess. The nurse also observes that Donna’s feet and ankles are swollen. When the nurse presses a finger over the client’s ankle (bony prominence), an 8 mm indentation appears. Donna has abnormal breath sounds, bilateral pitting edema, and jugular vein distention. Further findings include oxygen saturation level of 90%, serum sodium of 140 mEq/L, serum chloride 105 mmol/L, albumin 4 g/dL, AST 30 IU/L, and serum potassium of 3 mEq/L. Pharmacology: DiureticsDonna’s fluid volume excess improves and the prescription for hydrochlorothiazide (HydroDIURIL) 12.5 mg PO daily is restarted. Before Donna’s discharge, the nurse provides client teaching related to the prescribed hydrochlorothiazide (HydroDIURIL). Medication Administration: Oral TabletsIn preparing to administer the hydrochlorothiazide, the nurse notes that the prescribed dose is 12.5 mg, and the tablet available is 25 mg.Upon entering Donna’s room with the medication, the nurse checks Donna’s identification band. Donna states, “You take care of me every day. Why do you keep looking at my identification?” Donna’s fluid balance is restored. She is taking oral fluids well, her IV solution has been discontinued, and she has received client teaching about fluid balance and the correct administration of her diuretic. The nurse observes that Donna is able to break the scored medication tablet without difficulty. Donna is discharged home, accompanied by her daughter.
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