Question

Could you please do soap 3 cuz i did 1 and 2?

6:20 < Back SOAP Assignment #1.docx SOAP Assignment A 56-year-old African-American woman was acquaim with the medical staff because of frequent episodes of upper respiratory infections. The woman worked 0 on more hours per woek as a file clerk at a local ha department and was known as a hand worker. Despine what she desenibed as her "chronic oold. she rarely missed a day of work, althouph she frequently needed to roqguest permission to leave work early because of doctor compassionane person and understood the woman's all problem and froquent requests to leave carly The woman's hospital chart showod that hor rogatogy peoblems began when she was in her carly leens Ding that period, frequent upper respiratory tract infectices and an annoying cough had been her only symptoms. The chart also statod that she had been a smokar of ahout one pack of eigarettes per day during her leen years Over the years, she had quit and restarted smoking many times Fore previous several years, she had treated herselfw in her room most of the time. She frequently had been given anibiotics in alermating cycles. Her hasband efie administered chest percussion and postural drainage at home, and she found this treatment helpfl for acue are ups (cough and increased sputum peoduction). The weman stated that she had not smked foe 3 mcer Over the previous6 mons, however, she stated that she had lost both weight and her pencrally "pood spirtsShe further stated that her cough had been almost cotino with production of copious amounts of Soul-smelling purulent sputum. She denied hemoptysis. She alse indicatod that her co-workers had become conoemed about her condition and recommended that she seck immaliae medical anention PHYSICAL EXAMINATION (TIME: 0930) The patient appeared well nourished and complainod of severe, nearly constant shortness of breath; a fregaent appeared cyanotic, and her fingers and toes showed md clubbing. She performed punsed-lip breathing and wsod be Her vital signs were as follows: blood peessure 185 90 heart rate 110 bpm, respiratory rate 30 min, and oral emperature 37.9 C(1002" F) Palpation ofthe dhest and perousion of the lungs revealod no remarkable persistenm crackles over the lung bases wese heand airway obstruction on pulmonary function sests (PFTs) parformed 2 years ago. Her hisory also showed he

Answer 1

Answer :

SOAP - 3

S. Subjective data :

It means what information client tells to us, or health care providers.

Client is saying after treatment breathing is better. And still having pale ness, but cyanosis is reduced.

She is using lip breathing .

O - objective data : what health care professionals are observed from the client is called objective data.

According to this study objective data is to remarkable cyanosis and using accessary muscles to respiration.

A - assessment :

According to this study assessment done like

Asked for coughing, so client have thin clear secretions..

* vital signs are

Temperature : is normal

Pulse : 80 b / mt ,

Respiration : 14 b / mt ,

Blood pressure : 135/85 mm of hg.

On auscultation mild rhonchi and cracles heard in base of both lungs.

Oxygen saturation is 94 %.

And ABG values also altered.

P - planning :

* oxygen administration is needed still because 94 % of saturation levels.

* Nebulization should be given to reduce cracles.

* administrator intravenous fluids.

* administration of blood products because she is having pale.

* provide semi Fowlers or fowlers position.

* maintain intake and out put chart.

* continueous monitoring of client.

* and wean off oxygen according to doctors advice.