NR 602 Week 1 SOAP_Lataille_2020 – Chamberlain College of Nursing | NR602 Week 1 SOAP_Lataille_2020

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NR 602 Week 1 SOAP_Lataille_2020 – Chamberlain College of Nursing A.K. 65yo M S. CC- Weight Loss HPI- He is here today because in the past 2 mo. he has lost 18 lbs unintentionally. Not hun... gry and when he does eat he gets full fast. He is not eating as much as he used to, not hungry, eats 3 times a day. Feels more tired than usual, not sleeping well at night, daytime somnolence. His wife wakes him up at night when he is “snoring or when she thinks I am not breathing”. He states he used to have sleep apnea but not anymore. He is unable to tolerate a CPAP mask at night. O- 2 months ago L- Generalized abdomen D- 18lb weight loss over 2 months C- Anorexia, gets full fast, not eating as much as he used to, tired, daytime somnolence A-stopped wearing sleep apnea mask because it is uncomfortable R- None reported T- None reported S- None reported Current medications: Ibuprofen 600 mg po TID, Lisinopril 20 mg po QD, Hydrochlorothiazide 25 mg PO QD, Simvastatin 20 mg po QD, Vitamin D3 50,000 units po weekly, Omeprazole 40 mg po QD, Sudafed 50 mg po TID prn PMH- HTN, cataracts, osteoarthritis, and obstructive sleep apnea. Surgical history- April 2010-Right cataract extraction with Intraocular Lens Placement, June 2010- Left cataract extraction with Intraocular Lens Placement, November 2011-Left total knee arthroplasty  - - - - - - - - - - - - - - - - - - - - - - Nutritional supplements can be used to provide extra calories, they are available in liquid form, puddings, bars and soups. These supplements should be used to provide extra calories but not to replace meals (Gaddey & Holder, 2014). Diet modification to the patient’s preferences including softer foods and preferred consistency’s. Creating a stimulating eating environment may improve nutrition (Gaddey & Holder, 2014). The patient should consider seeing a dentist for his broken teeth and loose partial. Oral factors could contribute to his unintentional weight loss and low caloric intake (Gaddey & Holder, 2014). Education on vaccine recommendations: CDC recommends that people 60 years old and older get shingles vaccine to prevent shingles and PHN. The CDC also recommends that you get the influenza vaccine EVERY year and his last was 18 months ago. His TD is also up for renewal. Td is a tetanus-diphtheria vaccine given to adolescents and adults as a booster shot every 10 years, or after an exposure to tetanus under some circumstances. The CDC also recommends that 12 months after his pneumonia vaccine that he gets a prevnar vaccine. This vaccine is important because it protects against 13 types of pneumococcal bacteria (CDC, 2016). - - - - - - - - -- - - - - - - - - - - - -. (2016). Smoking and Tobacco Use Cessation. Retrieved from https://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx. Epocrates. (2015). Retrieved May 4, 2016, from Ibuprofen: https://online.epocrates.com/rxmain Fenstermacher, K. & Hundson, B. T. (2016). Practice Guidelines for Family Nurse Practitioners (4th ed.). St. Louis, MO: Elsevier. Gaddey, H. L. & Holder, K. (2014). Unintentional weight loss in older adults. American Family Physician, 89(9), 718-722. Short, M. W., Layton, M. C., Teer, B. N. & Domagalski, J. E. (2015). Colorectal cancer screening and surveillance. American Family Physcian, 91(2), 93-100. Wood, R., Camargo, C., & Lieberman, P. (2014). Anaphylaxis in America: the prevalence and characteristics of anaphylaxis in the United States. Journal of Allergy Clinical Immunology, 133(2), 461-467. [Show More]

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