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SOAP Note Case Study


Subjective section

R.A is a 16-year-old female with type 1diabetes first diagnosed 5 years ago. She is also obese and has hypothyroidism. She was binge drinking, but quit 2 years ago upon being advised that alcohol could worsen her health condition.

Unless when she has an emergency, she usually comes to the hospital for follow-up every month. Today, she has come for routine follow-up. Although she is asymptomatic, her blood pressure is 170/99 mmHg. She does not report any episodes or symptoms of hypoglycemia. She was using insulin, but stopped 8 months ago after she improved her condition.

Objective analysis

R.A has a healthy appearance and she is not characterized by signs of acute distress. Upon being physically examined, it is shown that she has a height of 165cm, weight of 90kg and a pulse rate of 86 beats per minute. The physical examination also reveals that she has a blood pressure of 170/99 mmHg. She does not present with retinopathy or thyromegaly (the retina is healthy and the thyroid glands are not inflamed). Also, she does not have diabetic foot ulcers that are common in diabetic patients.

Laboratory tests show that she has proteinuria, a cholesterol level of 230mg/dL, normal TSH levels, Hb level of 9.5%, creatinine level of 1.7mg/dL, glucose level of 190mg/dL, HDL and LDL of 134 and 35mg/dL respectively. Also, laboratory results reveal that she has normal electrolytes.

Assessment analysis

Related complications

These are complications with which the patient presents. They are the following:

  • Hypertension
  • Dyslipidemia
  • Nephropathy that is confirmed by proteins in the blood. It is an indication that kidney nephrons are not functioning well to ultra-filter blood. Thus, excreted urine has traces of proteins (Ludvigsson et al., 2008).

Risk factors

Risk factors could worsen type 1 diabetes in the patient. They are the following factors:

  • Obesity, which is indicated by a body mass index (BMI) of greater than 25.
  • Kidney malfunction (indicated by a high creatinine value of 1.7mg/dL).
  • Hypertension (readings are greater than 140/90 mmHg).
  • A1C>/= 5.7%.

Therapeutic goals

  • Clinical efforts should focus on controlling glycemia to A1C level less than 7%. (However, caution should be taken so that hypoglycemia cannot be caused in the process of controlling blood sugar).
  • It should be a goal to prevent cardiovascular disease from occurring in the patient (This could be a serious complication).
  • Reduce blood pressure to values lower than 130/80 mmHg. This is the recommended upper limit of blood pressure for diabetic patients (Ludvigsson et al., 2008).
  • Cardiovascular disease risks should be reduced by encouraging the patient to feed on food that helps to maintain healthy cholesterol levels. For healthy persons, the low density lipoprotein (LDL) should not exceed 100 (Ludvigsson et al., 2008).

Current medication

R.A says that she is not on medications. A treatment should be initiated to lower A1C and help to control symptoms associated with type 1diabetes and other conditions. Other therapies may also be started to help to prevent complications that are foreseeable in the near future (Bergenstal et al., 2010).

Plan

Further laboratory tests and work-up

  • Tests to assess liver functions. Biochemical liver tests determine levels of biochemical compounds crucial in regulating normal physiological functions. Elevated levels of biochemical in the liver would indicate that liver functions are altered.
  • In order to confirm that the patient has hypertension, blood pressure test would be repeated. If found to be normal, then the test will have to be conducted by many laboratories to determine the true values (Ludvigsson et al., 2008, Bergenstal et al., 2010).
  • CBC should be conducted so that infections can be ruled out or monitored. It is important to rule out infections in the patient because they could lead to worsening of her condition. Also, it is important to manage the infections with the right medications.
  • More history is needed that will capture the following details:
    • List of effective and failed medications.
    • A detailed family history to establish whether there are any relatives who have suffered from the same condition (type 1 diabetes) and the time of onset.
    • Immunizations received in the past and their clinical implications. A review would be done to assess whether previous immunizations could have interfered with the normal immune system of the patient.
    • Trends of adhering to medications offered in the past and barriers that hindered the patient from adhering to the medications. The medical history will help to select the best therapies to provide and ways of addressing barriers that could make the patient not take medications as prescribed (Ludvigsson et al., 2008).

Treatment recommendations

The diabetic patient will be put on insulin. In addition, she needs to adopt a healthy lifestyle that will involve feeding on a balanced diet characterized by significant amounts of carbohydrates. Also, body exercises will greatly help the patient to live a healthy life (Chase et al., 2008). Her blood pressure problem could be addressed by taking lisinopril 10mg daily.

Monitoring

  • Insulin use requires routine monitoring of blood glucose levels (Bergenstal et al., 2010).
  • Carbohydrate and fat dietary intake should be monitored. Total fat dietary intake should not be greater than 7% of the total number of sources of calories (Bergenstal et al., 2010).

Health education

Educational approaches should aim to inform the patient about ways of using medications so that they could improve her condition. Also, she will be taught how to maintain a healthy lifestyle. Healthy lifestyle changes will involve a healthy diet and aerobic exercises like walking and running (Chase et al., 2008; Bergenstal et al., 2010).

Follow-up and referrals

  • A1C should be routinely monitored for a period of 3 months.
  • Hypertension should be assessed at every routine visit.
  • LDL follow-up assessments could be done every 1-2 years.
  • Referrals will be recommended when her conditions worsen. They would involve being referred to physicians or healthcare facilities dealing with specific health conditions.

Cultural interventions

No cultural interventions are recommended for this patient.

Nursing theorist

The care, core and cure nursing theory would be used to offer care to the diabetic patient. The nursing theory was formulated by Lydia E. Hall and it asserts that a patient should set his or her goals (George, 2010). If the patient in the case study sets her goals, then she would work toward achieving them, and she would be influenced by her feelings and value system. The nursing theory would greatly impact the patient to improve her condition.

References

Bergenstal, R. M., Tamborlane, W. V., Ahmann, A., Buse, J. B., Dailey, G., Davis, S. N…. & Wood, M. A. (2010). Effectiveness of sensor-augmented insulin-pump therapy in type 1 diabetes. New England Journal of Medicine, 363(4), 311-320.

Chase, H. P., Fiallo-Scharer, R., Messer, L., Gage, V., Burdick, P., Laffel, L…. & Xing, D. (2008). Continuous glucose monitoring and intensive treatment of type 1 diabetes. N Engl J Med, 359(14), 1464-76.

George, J. B. (2010). Nursing theories. Upper Saddle River, NJ: Prentice Hall.

Ludvigsson, J., Faresjö, M., Hjorth, M., Axelsson, S., Chéramy, M., Pihl, M…. & Casas, R. (2008). GAD treatment and insulin secretion in recent-onset type 1 diabetes. New England Journal of Medicine, 359(18), 1909-1920.

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"SOAP Note." IvyPanda, 2 July 2020, ivypanda.com/essays/soap-note-case-study/.

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IvyPanda. "SOAP Note." July 2, 2020. https://ivypanda.com/essays/soap-note-case-study/.

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IvyPanda. 2020. "SOAP Note." July 2, 2020. https://ivypanda.com/essays/soap-note-case-study/.

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IvyPanda. (2020) 'SOAP Note'. 2 July.

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