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  • Nursing Care Plans For Asthma, Interventions and Overview – Best Nursing Care Plans(2022)

    This article discusses Asthma Nursing Diagnosis, causes, symptoms, preventions, care plans, and interventions.

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    Disclaimer: The information presented in this article is not medical advice; it is meant to act as a quick guide to nursing students for learning purposes only and should not be applied without an approved physician’s consent. Please consult a registered doctor in case you’re looking for medical advice.

    Introduction

    Asthma is an inflammatory disease of the airways to the lungs. It makes breathing difficult and can make some physical activities challenging or even impossible.

    According to the Centers for Disease Control and Prevention (CDC), about 25 million Americans have asthma. It’s the most common chronic condition among American children: 1 child out of every 12 has asthma.

    To understand asthma, it’s necessary to understand a little about what happens when you breathe. Normally, with every breath you take, air goes through your nose or mouth, down into your throat, and into your airways, eventually making it to your lungs.

    Symptoms of Asthma

    The most common symptom of asthma is wheezing. This is a squealing or whistling sound that occurs when you breathe.

    Other asthma symptoms may include:

    1. Coughing, especially at night, when laughing, or during exercise
    2. Tightness in the chest
    3. Shortness of breath
    4. Difficulty talking
    5. Anxiousness or panic
    6. Fatigue
    7. Chest pain
    8. Rapid breathing
    9. Frequent infections
    10. Trouble sleeping

    Classification of Asthma

    1. Extrinsic Asthma – called Atopic/allergic asthma. An “allergen” or an “antigen” is a foreign particle which enters the body. Our immune system over-reacts to these often harmless items, forming “antibodies” which are normally used to attack viruses or bacteria. Mast cells release these antibodies as well as other chemicals to defend the body.

    Common irritants:

    • Cockroach particles
    • Cat hair and saliva
    • Dog hair and saliva
    • House dust mites
    • Mold or yeast spores
    • Metabisulfite, used as a preservative in many beverages and some foods
    • Pollen

    2. Intrinsic asthma – called non-allergic asthma, is not allergy-related, in fact it is caused by anything except an allergy. It may be caused by inhalation of chemicals such as cigarette smoke or cleaning agents, taking aspirin, a chest infection, stress, laughter, exercise, cold air, food preservatives or a myriad of other factors.

    • Smoke
    • Exercise
    • Gas, wood, coal, and kerosene heating units
    • Natural gas, propane, or kerosene used as cooking fuel
    • Fumes
    • Smog
    • Viral respiratory infections
    • Wood smoke
    • Weather changes

    Causes of Asthma

    It isn’t clear why some people get asthma and others don’t, but it’s probably due to a combination of environmental and inherited (genetic) factors.

    Asthma triggers

    Exposure to various irritants and substances that trigger allergies (allergens) can trigger signs and symptoms of asthma. Asthma triggers are different from person to person and can include:

    Airborne allergens, such as pollen, dust mites, mold spores, pet dander or particles of cockroach waste

    Respiratory infections, such as the common cold

    Physical activity

    Cold air

    Air pollutants and irritants, such as smoke

    Certain medications, including beta blockers, aspirin, and nonsteroidal anti-inflammatory drugs, such as ibuprofen (Advil, Motrin IB, others) and naproxen sodium (Aleve)

    Strong emotions and stress

    Sulfites and preservatives added to some types of foods and beverages, including shrimp, dried fruit, processed potatoes, beer and wine

    Gastroesophageal reflux disease (GERD), a condition in which stomach acids back up into your throat

    Risk Factors of Asthma

    A number of factors are thought to increase your chances of developing asthma. They include:

    1. Having a blood relative with asthma, such as a parent or sibling
    2. Having another allergic condition, such as atopic dermatitis — which causes red, itchy skin — or hay fever — which causes a runny nose, congestion and itchy eyes
    3. Being overweight
    4. Being a smoker
    5. Exposure to secondhand smoke
    6. Exposure to exhaust fumes or other types of pollution
    7. Exposure to occupational triggers, such as chemicals used in farming, hairdressing and manufacturing

    Complications of Asthma

    Asthma complications include:

    • Signs and symptoms that interfere with sleep, work and other activities
    • Sick days from work or school during asthma flare-ups
    • A permanent narrowing of the tubes that carry air to and from your lungs (bronchial tubes), which affects how well you can breathe
    • Emergency room visits and hospitalizations for severe asthma attacks
    • Side effects from long-term use of some medications used to stabilize severe asthma
    • Proper treatment makes a big difference in preventing both short-term and long-term complications caused by asthma.

    Prevention of Asthma

    While there’s no way to prevent asthma, you and your doctor can design a step-by-step plan for living with your condition and preventing asthma attacks.

    Asthma is an ongoing condition that needs regular monitoring and treatment. Taking control of your treatment can make you feel more in control of your life.

    Get vaccinated for influenza and pneumonia. Staying current with vaccinations can prevent flu and pneumonia from triggering asthma flare-ups.

    Identify and avoid asthma triggers. A number of outdoor allergens and irritants — ranging from pollen and mold to cold air and air pollution — can trigger asthma attacks. Find out what causes or worsens your asthma, and take steps to avoid those triggers.

    Monitor your breathing. You may learn to recognize warning signs of an impending attack, such as slight coughing, wheezing or shortness of breath.

    But because your lung function may decrease before you notice any signs or symptoms, regularly measure and record your peak airflow with a home peak flow meter. A peak flow meter measures how hard you can breathe out. Your doctor can show you how to monitor your peak flow at home.

    Identify and treat attacks early. If you act quickly, you’re less likely to have a severe attack. You also won’t need as much medication to control your symptoms.

    When your peak flow measurements decrease and alert you to an oncoming attack, take your medication as instructed. Also, immediately stop any activity that may have triggered the attack. If your symptoms don’t improve, get medical help as directed in your action plan.

    Take your medication as prescribed. Don’t change your medications without first talking to your doctor, even if your asthma seems to be improving. It’s a good idea to bring your medications with you to each doctor visit. Your doctor can make sure you’re using your medications correctly and taking the right dose.

    Pay attention to increasing quick-relief inhaler use. If you find yourself relying on your quick-relief inhaler, such as albuterol, your asthma isn’t under control. See your doctor about adjusting your treatment.

    Diagnosis of Asthma

    There’s no single test or exam that will determine if you or your child has asthma. Instead, your doctor will use a variety of criteria to determine if the symptoms are the result of asthma.

    The following can help diagnose asthma:

    Health history. If you have family members with the breathing disorder, your risk is higher. Alert your doctor to this genetic connection.

    Physical exam. Your doctor will listen to your breathing with a stethoscope. You may also be given a skin test to look for signs of an allergic reaction, such as hives or eczema. Allergies increase your risk for asthma.

    Breathing tests. Pulmonary function tests (PFTs) measure airflow into and out of your lungs. For the most common test, spirometry, you blow into a device that measures the speed of the air.

    Doctors don’t typically perform breathing tests in children under 5 years of age because it’s difficult to get an accurate reading.

    Instead, they may prescribe asthma medications to your child and wait to see if symptoms improve. If they do, your child likely has asthma.

    For adults, your doctor may prescribe a bronchodilator or other asthma medication if test results indicate asthma. If symptoms improve with the use of this medication, your doctor will continue to treat your condition as asthma.

    Treatment of Asthma

    To help treat asthma, the National Asthma Education and Prevention Program (NAEPP)   classifies the condition based on its severity before treatment.

    Asthma classifications include:

    Intermittent. Most people have this type of asthma, which doesn’t interfere with daily activities. Symptoms are mild, lasting fewer than 2 days per week or 2 nights per month.

    Mild persistent. The symptoms occur more than twice a week — but not daily — and up to 4 nights per month.

    Moderate persistent. The symptoms occur daily and at least 1 night every week, but not nightly. They may limit some daily activities.

    Severe persistent. The symptoms occur several times every day and most nights. Daily activities are extremely limited.

    Treatments for asthma fall into four primary categories:

    1. Quick relief medications
    2. Long-term control medications
    3. A combination of quick relief and long-term control medications. The most current asthma clinical guidelines, released in 2020 by the NAEPP, recommend this treatment. However this treatment is not yet approved by the federal drug administration (FDA).
    4. Biologics, which are given by injection or infusion usually only for severe forms of asthma

    Nursing Diagnosis for Asthma

    1. Ineffective Breathing Pattern
    2. Ineffective Airway Clearance
    3. Anxiety

    Nursing Care Plans for Asthma Based on Nursing Diagnosis

    Nursing Care Plan 1: Ineffective Breathing Pattern

    Related Factors

    Swelling and spasm of the bronchial tubes in response to inhaled irritants, infection, drugs, allergies or infection.

    Defining Characteristics

    The common assessment cues that could serve as defining characteristics or part of your “as evidenced by” in your diagnostic statement.

    • Cough
    • Cyanosis
    • Dyspnea
    • Loss of consciousness
    • Nasal flaring
    • Prolonged expiration
    • Respiratory depth changes
    • Tachypnea
    • Use of accessory muscles

    Desired Outcomes

    Patient will maintain optimal breathing pattern, as evidenced by relaxed breathing, normal respiratory rate or pattern, and absence of dyspnea.

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    Nursing Care Plans For Asthma
    Nursing Care Plans For Asthma

    Nursing Interventions and Rationales

    Here are the nursing assessment and interventions for this asthma nursing care plan.

    Nursing InterventionsRationale
    Nursing Assessment
    Assess the client’s vital signs as needed while in distress.Increased BP, RR, and HR occur during the initial hypoxia and hypercapnia. And when it becomes severe, BP and HR drops and respiratory failure may result.
    Assess the respiratory rate, depth, and rhythm.Changes in the respiratory rate and rhythm may indicate an early sign of impending respiratory distress.
    Assess the client’s level of anxiety.Anxiety may result from the struggle of not being able to breathe properly.
    Assess breath sounds and adventitious sounds such as wheezes and stridor.Adventitious sounds may indicate a worsening condition or additional developing complications such as pneumonia. Wheezing happens as a result of bronchospasm. Diminishing wheezing and indistinct breath sounds are suggestive findings and indicate impending respiratory failure.
    Assess the relationship of inspiration to expiration.Reactive airways allow air to move into the lungs more easily than out of the lungs. If the client is gasping for air, instruction for effective breathing is needed.
    Assess for signs of dyspnea (flaring of nostrils, chest retractions, and use of accessory muscle).These indicate respiratory distress. Once the movement of air into and out of the lungs becomes challenging, the breathing pattern changes.
    Assess for conversational dyspnea.Dyspnea during a normal conversation is a sign of respiratory distress.
    Assess for fatigue.Fatigue may indicate distress, leading to respiratory failure.
    Assess the presence of paradoxical pulse of 12 mm Hg or greater.Paradoxical pulse is an abnormally large decrease in systolic blood pressure and pulses wave amplitude during inspiration. The normal fall in pressure is less than 10 mm Hg. A paradoxical pulse of 12 mm Hg or greater indicates a severe airflow obstruction.
    Monitor oxygen saturation.Oxygen saturation is a term referring to the fraction of oxygen-saturated hemoglobin relative to the total hemoglobin in the blood. Normal oxygen saturation levels are considered 95-100%.
    Monitor peaked expiratory flow rates and forced expiratory volume as taken by the respiratory therapist.The severity of the exacerbation can be measured objectively by monitoring these values. The peak expiratory flow rate is the maximum flow rate that can be generated during a forced expiratory maneuver with fully inflated lungs. It is measured in liters per second and requires maximal effort. When done with good effort, it correlates well with forced expiratory volume in 1 second (FEV1) measured by spirometry and provides a simple, reproducible measure of airway obstruction.
    Monitor arterial blood gasses (ABG).During a mild to moderate asthma attack, clients may develop respiratory alkalosis. Hypoxemia leads to increased respiratory rate and depth, and carbon dioxide is blown off. An ominous finding is a respiratory acidosis, which usually indicates that respiratory failure is pending and that mechanical ventilation may be necessary.
    Therapeutic Interventions
    Plan for periods of rest between activities.Fatigue is common with the increased work of breathing from the ineffective breathing pattern. Activity increases metabolic rate and oxygen requirements.
    Maintain head of bed elevated.This promotes maximum lung expansion and assists in breathing.
    Encourage client to use pursed-lip breathing for exhalation.Pursed lip breathing improves breathing patterns by moving old air out of the lungs and allowing for new air to enter the lungs.
    Administer medication as ordered:
    Short-acting beta-2-adrenergic agonist. Albuterol (Proventil, Ventolin). Levalbuterol (Xopenex). Terbutaline (Brethine).Short-acting beta2-agonists are bronchodilators. They relax the muscles lining the airways that carry air to the lungs; treatment of choice for acute exacerbation of asthma.
    Inhaled Corticosteroids. Budesonide (Pulmicort). Fluticasone (Flovent). Beclomethasone (Vancenase). Mometasone (Asmanex Twisthaler).Corticosteroids reduce inflammation in the airways that carry air to the lungs and reduce the mucus made by the bronchial tubes. Inhaled steroids should be given after beta-2-adrenergic agonist.
    Anticipate the need for alternative treatment if life-threatening bronchospasm continues:
    General anesthesia.General anesthesia is used when there is both dynamic hyperinflation and profound hypercapnia that cannot be corrected by increasing minute ventilation.
    Magnesium sulfate.Magnesium sulfate has bronchodilating and anti-inflammatory effects that are sometimes used in the treatment of moderate to severe asthma in children.
    Heliox (a helium-oxygen mixture).The use of helium (a less dense gas than nitrogen) causes decrease airway resistance thus lessens the work of breathing.

    Nursing Care Plan 2: Ineffective Airway Clearance

    Related Factors

    • Bronchospasms
    • Increased pulmonary secretions
    • Ineffective cough
    • Mucosal edema

    Defining Characteristics

    The common assessment cues that could serve as defining characteristics or part of your “as evidenced by” in your diagnostic statement.

    • Abnormal arterial blood gasses
    • Adventitious lung sounds (Wheezes, Rhonchi)
    • Changes in respiratory rate and rhythm
    • Chest tightness
    • Cough
    • Cyanosis
    • Dyspnea; orthopnea
    • Retained secretions

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    Nursing Care Plans For Asthma
    Nursing Care Plans For Asthma

    Desired Outcomes

    Common goals and expected outcomes:

    • Patient will verbalize understanding of cause and therapeutic management regimen.
    • Patient will maintain airway patency as evidenced by clear breath sounds, improved oxygen exchange, normal rate and depth of respiration, and ability to effectively cough out secretions.

    Nursing Interventions and Rationales

    Here are the nursing assessment and interventions for this asthma nursing care plan.

    Nursing InterventionsRationale
    Nursing Assessment
    Assess respiratory rate, depth, and rhythm.Changes in the respiratory rate and rhythm may indicate an early sign of impending respiratory distress.
    Assess for color changes in the buccal mucosa, lips, and nail beds.Cyanosis indicates low oxygenation and that breathing is ineffective to maintain adequate tissue oxygenation.
    Auscultate lungs for adventitious breath sounds (wheezes and rhonchi).Wheezes suggest partial obstruction or resistance. While rhonchi may indicate retained secretions in the lungs.
    Assess the effectiveness of cough.Coughing is a natural way to clear the throat and breathing passage of foreign particles, irritants, and mucus. Severe bronchospasm, thick secretions, and respiratory muscle fatigue are some of the causes of an ineffective cough.
    Assess the amount, color, odor and viscosity of the secretions.Normal secretion is clear or gray and minimal; abnormal sputum is green, yellow, or bloody; malodorous; often copious. Thick tenacious secretions increase airway resistance.
    Monitor and record intake and output (I&O) adequately.Provides information on the fluid balance of the patient. Dehydration can contribute in viscous secretions and may result to decrease airway clearance.
    Monitor oxygen saturation using pulse oximetry.Oxygen saturation of less than 90% indicates problems with oxygenation.
    Monitor chest x-ray results.A chest x-ray provides information regarding the presence of infiltrates, lung inflation, or the presence of barotrauma.
    Monitor laboratory results as indicated:
    White blood cell countIncreased WBC count indicates an infection.
    PotassiumThe use of beta-adrenergic agonists shift potassium into the cell and cause hypokalemia.
    Theophylline level (if on theophylline therapy)Therapeutic range of theophylline is between 10 to 20 mcg/mL. Signs of toxicity include hypotension, tachycardia, GI symptoms, and restlessness.
    Monitor arterial blood gasses (ABGs).Retention of carbon dioxide happens due to fatigue from labored breathing caused by bronchospasm. Once the client is mechanically ventilated, permissive hypercapnia may be utilized to prevent lung damage and maintain plateau pressure less than 30 to 35 cm H20.
    Obtain peak expiratory flow rate (PEFR) or forced expiratory volume in 1 second (FEV1) before and after respiratory treatment.Peak expiratory flow rate (PEFR) is the maximum flow rate generated during forceful exhalation. It should be improved with effective therapy. FEV1  is the volume exhaled during the first second of a forced expiratory maneuver started from the level of total lung capacity.
    Therapeutic Interventions
    Pace the client’s activities.Break up activities into smaller parts and take rest breaks in between to avoid fatigue. increased effort in breathing properly.
    Encourage deep breathing and coughing exercises.Helps loosen and expectorate excess secretions and contribute in effective clearing mucus out of the lungs.
    Encourage increased fluid intake of up to 3000 ml/day within cardiac or renal reserve.Fluids help minimize mucosal drying and increases ciliary action to remove secretions.
    Limit alcohol and caffeinated drinks.When consumed in excess, it may contribute to dehydration making difficulty for secretions to be expectorated. In addition, it may also increased the risk of CNS and cardiovascular system side effects of medications.
    Administer IV fluids and medication as ordered.IV fluid therapy can be beneficial for clients with dehydration. Medications such as bronchodilators and inhaled corticosteroids may be prescribed.
    Administer oxygen as ordered.Oxygen therapy corrects hypoxemia, which can be caused by retained respiratory secretions.
    Anticipate the need for intubation and mechanical ventilation.Acute exacerbations of asthma can lead to respiratory failure requiring mechanical ventilation.

    Nursing Care Plan 3: Anxiety

    Related Factors

    • Change in the environment
    • Change in health status
    • Loss of control
    • Hypoxia
    • Respiratory distress

    Defining Characteristics

    The common assessment cues that could serve as defining characteristics or part of your “as evidenced by” in your diagnostic statement.

    • Apprehensiveness
    • Dyspnea
    • Frequent request for someone to be in the room
    • Restlessness
    • Tachycardia
    • Tachypnea

    Desired Outcomes

    Common goals and expected outcomes:

    • Patient will use an effective coping mechanism.
    • Patient will verbalize a reduction in level of anxiety experienced.
    • Patient will demonstrate reduced anxiety as evidenced by a calm demeanor and cooperative behavior.

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    Nursing Care Plans For Asthma
    Nursing Care Plans For Asthma

    Nursing Interventions and Rationales

    Here are the nursing assessment and interventions for this seizure nursing care plan.

    Nursing InterventionsRationale
    Nursing Assessment
    Assess for signs of anxiety: Feelings of panic, fear, and uneasiness. Tachycardia. Cold or sweaty hands or feet. Shortness of breath. Restlessness.Asthma can become much worse with anxiety since it causes rapid, shallow breathing.
    Assess theophylline levels.Therapeutic range of theophylline is between 10 to 20 mcg/mL. Theophylline causes increases anxiety.
    Monitor oxygen saturation.Increase anxiety may indicate an early sign of hypoxia.
    Therapeutic Interventions
    Provide comfort measures: Calm, quiet environment. Soft music.Maintaining calmness will reduce oxygen consumption and the work of breathing.
    Explain every procedure to the client in a simple and concise manner.Client’s anxiety will decrease as he or she can understand the treatment regimen.
    Ensure to update the significant others of the client’s progress.Family’s anxiety can be easily transferred to the client. Giving off information to them can help relieve apprehension.
    Stay with the client, and encourage slow, deep breathing. Assure the client and significant others of close, consistent monitoring that will ensure prompt intervention.The presence of a trusted reliable person may give the client a sense of security.
    Encourage the use of relaxation techniques: Progressive muscle relaxation as indicated. Diaphragmatic and pursed lip breathing. Use of imagery, repetitive phrases (repeating a phrase that triggers a physical relaxation, such as “relax and let go”).Relaxation techniques are an effective way of decreasing anxiety.

    Related FAQs

    1. What is the main cause of asthma?

    Contact with allergens, certain irritants, or exposure to viral infections as an infant or in early childhood when the immune system isn’t fully mature have been linked to developing asthma. Exposure to certain chemicals and dusts in the workplace may also play a significant role in adult-onset asthma.

    2. What are 5 causes of asthma?

    Asthma Causes and Triggers

    • Infections like sinusitis, colds, and the flu.
    • Allergens such as pollens, mold, pet dander, and dust mites.
    • Irritants like strong odors from perfumes or cleaning solutions.
    • Air pollution.
    • Tobacco smoke.
    • Exercise.
    • Cold air or changes in the weather, such as temperature or humidity.

    3. What are the 3 types of asthma?

    Common asthma types include: Allergic asthma. Non-allergic asthma. Cough-variant

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    Nursing Care Plans For Asthma
    Nursing Care Plans For Asthma

    4. What makes asthma worse at night?

    The exact reason that asthma is worse during sleep are not known, but there are explanations that include increased exposure to allergens; cooling of the airways; being in a reclining position; and hormone secretions that follow a circadian pattern. Sleep itself may even cause changes in bronchial function.

    Read More:

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  • Nursing Care Plans For Anxiety Plus Interventions – Best Nursing Care Plans(2022)

    This article discusses Anxiety Nursing Diagnosis, causes, symptoms, preventions, care plans, and interventions.

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    Disclaimer: The information presented in this article is not medical advice; it is meant to act as a quick guide to nursing students for learning purposes only and should not be applied without an approved physician’s consent. Please consult a registered doctor in case you’re looking for medical advice.

    Introduction

    Anxiety is a feeling of fear, dread, and uneasiness. This is a necessary emotional response for survival, a normal response to a threatening situation. It may result in sweating, feeling restlessness, and tensing.

    Stress is the pressure that is brought to bear on the individual. It can result in anxiety. Mainly is brought about by emotional complications, relationship problems, deadlines, and physical ailments.

    Fear is an innate intellectual response to dangerous or life-threatening situations.

    Anxiety and panic can disrupt daily tasks, be challenging to regulate, be out of proportion to the actual risk, and last long. To avoid unpleasant feelings, you may avoid certain places or circumstances. Symptoms may appear in childhood or adolescence and persist throughout maturity.

    Generalized anxiety disorder, social anxiety disorder (social phobia), particular phobias, and separation anxiety disorder are examples of anxiety disorders. There is a possibility that a person will have more than one anxiety disorder. Anxiety might be caused by a medical issue that requires treatment.

    Signs and Symptoms of Anxiety

    The following are some of the most common anxiety indications and symptoms:

    1. Feeling jittery, agitated, or tense
    2. Feelings of impending danger, terror, or impending disaster
    3. An elevated heart rate is a condition in which your heart beats faster than usual.
    4. Rapid breathing (hyperventilation)
    5. Sweating
    6. Trembling
    7. Feeling tired or weak
    8. Having difficulty concentrating or thinking about anything other than your current concern
    9. Having difficulty sleeping
    10. Having troubles with your gastrointestinal tract (GI tract)
    11. Having trouble managing your anxiety
    12. Having a strong desire to avoid situations that cause uneasiness.

    Types of Anxiety Disorders

    Agoraphobia is an anxiety disorder in which you fear and frequently avoid locations or situations that may make you feel imprisoned, helpless, or embarrassed.

    Anxiety disorder caused by a medical disease comprises severe anxiety or panic symptoms triggered directly by a physical health problem.

    Generalized anxiety disorder is characterized by persistent and excessive anxiety and stress about everyday activities and occurrences. Worry is out of proportion to the situation, is impossible to control, and impacts your physical well-being. It frequently happens in the presence of other anxiety disorders or depression.

    Panic disorder is characterized by recurring bouts of severe anxiety, fear, or terror that peak within minutes (panic attacks). Feelings of impending doom, shortness of breath, chest pain, or a racing, fluttering, or pounding heart are all possible symptoms (heart palpitations). These panic episodes may cause you to worry about them happening again or avoid settings where they have already happened.

    Selective mutism is a condition in which children refuse to talk in specific environments, such as school, yet can communicate in other settings, such as at home with close family members. This can cause problems at school, work, and social situations.

    Separation anxiety disorder is a childhood disorder characterized by excessive anxiety for the child’s developmental level and related to separation from parents or others who have parental roles.

    Social anxiety disorder (social phobia) involves high levels of anxiety, fear, and avoidance of social situations due to feelings of embarrassment, self-consciousness, and concern about being judged or viewed negatively by others.

    Specific phobias are characterized by significant anxiety when you’re exposed to a specific object or situation and a desire to avoid it. Phobias provoke panic attacks in some people.

    Substance-induced anxiety disorder is characterized by symptoms of intense anxiety or panic that directly result from misusing drugs, taking medications, being exposed to a toxic substance, or withdrawing from drugs.

    Types of Phobias

    Social anxiety disorder (social phobia)

    • Severe, persistent, and irrational fear of social or performance situations
    • Fears concerning excessive sweating and blushing – important
    • Fear of negative evaluation by others – a key component
    • Broad or narrow trigger situations
    • Avoidance of social conditions in particular
    • 11% of men and 15% of women 

    Agoraphobia

    • Anxiety about being in places or situations where escape might be difficult or where help is not available if the individual were to have a panic attack or pass out
    • May lead to avoidance of specific places and spaces
    • Depersonalization and derealisation
    • It is often diagnosed in conjunction with panic disorder.

    Psychoanalytic theory of phobias

    • Conscious phobic objects represent unconscious childhood fears
    • This is a defense mechanism called displacement: shifting of thoughts/emotions from one target to another, often a related target (phobic object), because first is unavailable to the conscious mind (too painful)
    • Phobic object – has symbolic value, as it may represent an underlying fear

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    Behavioral theory of phobias

    A person learns phobias through object associations with a painful or frightening stimulus.

    Classical conditioning – e.g., Little Albert [J. B. Watson]

    • Induced fear of the rat
    • Unconditioned stimulus: a stimulus – loud noise – that elicits a fear response
    • Conditioned stimulus: a stimulus- white rat – that does not elicit US response
    • Associative learning: pairing CS with the US leads to a conditioned response to CS in the absence of US

    Operant conditioning – fear of flying

    • The setting the behavior occurs in – e.g., flying.
    • The reinforced response – e.g., avoidance of flying
    • The reinforcer – e.g., traveling by car

    Risk factors for Anxiety

    These factors may increase your risk of developing an anxiety disorder:

    Trauma. Children who endured abuse or trauma or witnessed traumatic events are at higher risk of developing an anxiety disorder at some point in life. Adults who experience a traumatic event also can develop anxiety disorders.

    Stress due to an illness. Having a health condition or serious illness can cause significant worry about your treatment and future.

    Stress buildup. A significant event or a buildup of more minor stressful life situations may trigger excessive anxiety, such as a family death, work stress, or ongoing worry about finances.

    Personality. People with certain personality types are more prone to anxiety disorders than others are.

    Other mental health disorders. People with other mental health disorders, such as depression, often also have an anxiety disorder.

    Having blood relatives with an anxiety disorder. Anxiety disorders can run in families.

    Drugs or alcohol. Drug or alcohol use or misuse, or withdrawal can cause or worsen anxiety.

    Other specified anxiety disorders and unspecified anxiety disorders are terms for anxiety or phobias that don’t meet the exact criteria for any other anxiety disorders but are significant enough to be distressing and disruptive.

    Diagnosis of Anxiety Disorders

    Psychological exam – to discuss thoughts, emotions or feelings, life experiences, and behavior that can help diagnose anxiety or other mental health disorder; can be carried out by a psychiatrist or a psychologist.

    Use of DSM-5 – the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) is a widely used medical manual containing criteria for diagnosing mental health disorders.

    History Taking -to check for physical symptoms of anxiety; to check for substance use or withdrawal.

    Electrocardiogram (ECG) – may be used if the patient has chest pain to rule out a cardiac event.

    Treatment for Anxiety Disorders

    1. Psychotherapy. Also called psychological counseling or talk therapy, this treatment for anxiety disorders involves speaking with a licensed therapist and gradually coping with the symptoms. Psychotherapy is an effective and proven treatment for anxiety disorders. There are many forms of psychotherapy, but cognitive behavioral therapy (CBT) is found to be the most effective. CBT aims to help the patient develop specific skills to cope with anxiety symptoms and slowly go back to the activities that the patient has been avoiding. It involves exposing the patient gradually to the trigger/s of their anxiety.

    2. Medications. Anxiolytic medications and certain antidepressants are often prescribed for anxiety disorders. Sedatives such as benzodiazepines may be prescribed for short-term anxiety relief. A group of antidepressants called selective serotonin reuptake inhibitors (SSRIs) is effectively used with CBT.

    3. Lifestyle changes. Being physically active can reduce stress levels, improve mood, and help maintain a healthy body. Nicotine, caffeine, recreational drugs, and alcohol should be avoided as they can worsen anxiety symptoms. Getting enough sleep can help the person feel relaxed. Meditation, yoga, guided imagery, and deep breathing exercises can also relax the mind and reduce the symptoms. Keeping a journal can help the patient understand what triggers their anxiety and what increases their stress levels and what makes them calm and relaxed.

    4. Anxiety support group. The patient can be referred to an anxiety support group where they can participate in the discussion of relatable experiences and experience compassion from others.

    Nursing Diagnosis for Patients with Anxiety

    1. Anxiety
    2. Fear
    3. Ineffective Coping
    4. Powerlessness

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    Nursing Care Plans For Anxiety
    Nursing Care Plans For Anxiety

    Nursing Care Plans for Anxiety Based on Diagnosis

    Nursing Care Plan 1: Anxiety

    Nursing diagnosis of anxiety may be related to:

    • Lack of knowledge regarding symptoms, progression of the condition, and treatment regimen.
    • The actual or perceived threat to biological integrity.
    • Unconscious conflict about essential values and goals of life.
    • Situational and maturational crises.

    Possibly evidenced by:

    • Decreased attention span
    • Restlessness
    • Poor impulse control
    • Hyperactivity, pacing
    • Feelings of discomfort, apprehension, or helplessness
    • Delusions
    • Disorganized thought process
    • Inability to discriminate harmful stimuli or situations

    Desired Outcomes

    1. Be free from injury
    2. Discuss feelings of dread, anxiety, and so forth
    3. Respond to relaxation techniques with a decreased anxiety level.
    4. Reduce own anxiety level.
    5. Be free from anxiety attacks.
    Nursing InterventionsRationale
    Maintain a calm, non-threatening manner while working with the client.Anxiety is contagious and may be transferred from health care provider to client or vice versa. The client develops a feeling of security in the presence of a calm staff person.
    Establish and maintain a trusting relationship by listening to the client, displaying warmth, answering questions directly, offering unconditional acceptance, being available, and respecting the client’s use of personal space.Therapeutic skills need to be directed toward putting the client at ease because the stranger’s nurse may pose a threat to the highly anxious client.
    Remain with the client at all times when levels of anxiety are high (severe or panic); reassure the client of their safety and security.The client’s safety is the utmost priority. A highly anxious client should not be left alone as his anxiety will escalate.
    Move the client to a quiet area with minimal stimuli such as a small room or seclusion area (dim lighting, few people, and so on.)Anxious behavior escalates by external stimuli. A smaller or secluded area enhances a sense of security compared to a large area, making the client feel lost and panicked.
    Maintain calmness in your approach to the client.The client will feel more secure if you are calm and inf the client feels you are in control of the situation.
    Provide reassurance and comfort measures.Helps relieve anxiety.
    Educate the patient, and SO that anxiety disorders are treatable.Pharmacological therapy is an effective treatment for anxiety disorders; treatment regimens may include antidepressants and anxiolytics.
    Support the client’s defenses initially.The client uses defenses in an attempt to deal with an unconscious conflict, and giving up these defenses prematurely may cause increased anxiety.
    Maintain awareness of your own feelings and level of discomfort.Anxiety is communicated interpersonally. Being with an anxious client can raise your own anxiety level. Discussion of these feelings can provide a role model for the client and show a different way of dealing with them.
    Stay with the patient during panic attacks. Use short, simple directions.During a panic attack, the patient needs reassurance that he is not dying and the symptoms will resolve spontaneously. In anxiety, the client’s ability to deal with abstractions or complexity is impaired.
    Avoid asking or forcing the client to make choices.The client may not make sound and appropriate decisions or may be unable to make decisions at all.
    Observe for increasing anxiety. Assume a calm manner, decrease environmental stimulation, and provide temporary isolation as indicated.Early detection and intervention facilitate modifying the client’s behavior by changing the environment and interaction with it to minimize the spread of anxiety.
    PRN medications may be indicated for high levels of anxiety. Watch out for adverse side effects.Medication may be necessary to decrease anxiety to a level at which the client can feel safe.
    Encourage the client’s participation in relaxation exercises such as deep breathing, progressive muscle relaxation, guided imagery, meditation, and so forth.Relaxation exercises are effective nonchemical ways to reduce anxiety.
    Teach signs and symptoms of escalating anxiety and ways to interrupt its progression (e.g., relaxation techniques, deep-breathing exercises, physical exercises, brisk walks, jogging, meditation).So the client can start using relaxation techniques; gives the client confidence in having control over his anxiety.
    Administer SSRIs as ordered.Panic attacks are caused by a neuropsychiatric disorder that responds to SSRI antidepressants.
    Help the client see that mild anxiety can be a positive catalyst for change and does not need to be avoided.The client may feel that all anxiety is bad and not useful.

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    Nursing Care Plans For Anxiety
    Nursing Care Plans For Anxiety

    Nursing Care Plan 2: Fear

    Nursing diagnosis of fear may be related to:

    • Phobic stimulus
    • Physiological symptoms, mental/cognitive behaviors indicative of panic

    Possibly evidenced by:

    • Acknowledge and discuss fears.
    • Demonstrate understanding by using effective coping behaviors and active participation in the treatment regimen.
    • Resume normal life activities.

    Desired Outcomes

    1. The client will be able to discuss phobic objects or situations with the nurse.
    2. The client will be able to function in the presence of a phobic object or situation without experiencing panic anxiety by the time of discharge from treatment.
    Nursing InterventionsRationale
    Reassure the client of his safety and security.At panic level anxiety, the client may fear for their own life.
    Explore client’s perception of threat to physical integrity or threat to self-concept.Understanding the client’s perception of the phobic object or situation is important to assist with the desensitization process.
    Present and discuss the reality of the situation with the client to recognize aspects that can be changed and those that cannot.The client must accept the reality of the situation before the work of reducing the fear can progress.
    Suggest that the client substitute positive thoughts for negative ones.Emotion is connected to thought, and changing to a more positive thought can decrease the level of anxiety experienced. This also gives the client an alternative way of looking at the problem.
    Include client in making decisions related to the selection of alternative coping strategies.Allowing the client choices provides a measure of control and serves to increase feelings of self-worth.
    Encourage the client to explore underlying feelings that may be contributing to irrational fears. Help the client to understand how facing these feelings, rather than suppressing them, can result in more adaptive coping abilities.Verbalization of feelings in a non-threatening environment may help the client come to terms with unresolved issues.
    Discuss the process of thinking about the feared object/situation before it occurs.Anticipation of a future phobic reaction allows the client to deal with the physical manifestations of fear.
    Encourage the client to share the seemingly unnatural fears and feelings with others, especially the nurse therapist.Clients are often reluctant to share feelings for fear of ridicule and may have repeatedly been told to ignore feelings. Once the client begins to acknowledge and talk about these fears, it becomes apparent that the feelings are manageable.
    Encourage to stop, wait, and not rush out of the feared situation as soon as experienced. Support use of relaxation exercises.The client fears disorganization and loss of control of body and mind when exposed to the fear-producing stimulus. This fear leads to an avoidance response, and reality is never tested. If the client waits out the beginnings of anxiety and decreases it with relaxation exercises, then they may be ready to continue confronting the fear.
    Explore things that may lower fear level and keep it manageable (e.g., singing while dressing, repeating a mantra, practicing positive self-talk while in a fearful situation).Provides the client with a sense of control over the fear. Distracts the client so that fear is not totally focused on and allowed to escalate.
    Use desensitization approach:
    Systematic desensitizationSystematic desensitization (gradual, systematic exposure of the client to the feared situation under controlled conditions) allows the client to begin to overcome the fear, become desensitized to the fear. Note: Implosion or flooding (continuous, rapid presentation of the phobic stimulus) may show quicker results than systematic desensitization, but relapse is more common, or the client may become terrified and withdraw from therapy.
    Expose the client to a predetermined list of anxiety-provoking stimuli rated in the hierarchy from the least frightening to the most frightening.Experiencing fear in progressively more challenging but attainable steps allows the client to realize that dangerous consequences will not occur. Helps extinguish conditioned avoidance response
    Pair each anxiety-producing stimulus (e.g., standing in an elevator) with the arousal of another effect of an opposite quality (e.g., relaxation, exercise, biofeedback) strong enough to suppress anxiety.It helps the client to achieve physical and mental relaxation as the anxiety becomes less uncomfortable.
    Help client to learn how to use these techniques when confronting an actual anxiety-provoking situation. Provide for practice sessions (e.g.role-play), deal with phobic reactions in real-life situations.The client needs a continued confrontation to gain control over fear. Practice helps the body become accustomed to the feeling of relaxation, enabling the individual to handle feared objects/situations.

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    Nursing Care Plans For Anxiety
    Nursing Care Plans For Anxiety

    Nursing Care Plan 3: Ineffective Coping

    Nursing diagnosis of ineffective coping may be related to:

    • Situational crises
    • Maturational crises
    • Fear of failure

    Possibly evidenced by:

    • Ritualistic behavior or obsessive thoughts
    • Inability to meet basic needs
    • Inability to meet role expectations
    • Inadequate problem solving

    Desired Outcomes

    1. The client will decrease participation in ritualistic behavior.
    2. The client will demonstrate the ability to cope effectively.
    3. The client will verbalize signs and symptoms of increased anxiety and intervene to maintain anxiety at a manageable level.
    4. The client will demonstrate the ability to interrupt obsessive thoughts and refrain from ritualistic behaviors.
    Nursing InterventionsRationale
    Assess the client’s level of anxiety. Investigate the types of situations that increase anxiety and result in ritualistic behaviors.Helping the client recognize the precipitating factors is the first step in teaching the client to interrupt the escalating anxiety.
    Initially meet the client’s dependency needs as necessary.Sudden and complete elimination of avenues for dependency would create anxiety and will burden the client more.
    Encourage independence and give positive reinforcement for independent behaviors.Positive reinforcement enhances self-esteem and encourages repetition of desired behaviors.
    During the beginning of treatment, allow plenty of time for rituals. Do not be judgmental or verbalize disapproval of the behavior.To deny the client, this activity can precipitate a panic level of anxiety.
    Support and encourage the client’s efforts to explore the meaning and purpose of the behavior.The client may be unaware of the relationship between emotional problems and compulsive behaviors. Recognition and acceptance of problems are important before change can occur.
    Gradually limit the amount of time allotted for ritualistic behavior as the client becomes more involved in unit activities.Anxiety is minimized when the client is able to replace ritualistic behaviors with more adaptive ones.
    Encourage the recognition of situations that provoke obsessive thoughts or ritualistic behaviors.Recognition of precipitating factors is the first step in teaching the client to interrupt escalation of anxiety.
    Provide positive reinforcement for nonritualistic behaviors.Positive reinforcement enhances self-esteem and encourages repetition of desired behaviors.

    Nursing Care Plan 4: Powerlessness

    Nursing diagnosis of powerlessness may be related to:

    • Lifestyle of helplessness
    • Fear of disapproval from others
    • Consistent negative feedback

    Possibly evidenced by:

    • Apathy
    • Dependence on others may result in irritability, resentment, anger, and guilt.
    • Verbal expressions of having no control
    • Nonparticipation in care or decision-making when opportunities are provided.
    • Reluctance to express true feelings.

    Desired Outcomes

    1. The client will participate in decision-making regarding their own care.
    2. The client will be able to problem-solve ways to take control of their life situation effectively.
    Nursing InterventionsRationale
    Have clients take as much responsibility for their own self-care practices.Providing clients with choices and responsibilities will increase their feelings of control.
    Help client set realistic goals.Unrealistic goals set the client up for failure and reinforce feelings of powerlessness.
    Help identify areas of life situations that the client can control.The client’s emotional condition prevents his ability to solve problems. Support is required to perceive the benefits and consequences of available alternatives.
    Help the client identify areas of life situation that are not with his ability to control; encourage verbalization of these feelings.To deal with unresolved issues and accept what cannot be changed.
    Identify ways and instances in which the client can achieve and encourage participation in these activities; provide positive reinforcement for participation.Positive reinforcement enhances self-esteem and encourages repetition of positive behaviors.

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    Nursing Care Plans For Anxiety
    Nursing Care Plans For Anxiety

    Related FAQs

    1. What are 5 symptoms of anxiety?

    Symptoms

    • Feeling nervous, restless or tense.
    • Having a sense of impending danger, panic or doom.
    • Having an increased heart rate.
    • Breathing rapidly (hyperventilation)
    • Sweating.
    • Trembling.
    • Feeling weak or tired.
    • Trouble concentrating or thinking about anything other than the present worry.

    2. What do anxiety feel like?

    feeling tense, nervous or unable to relax. having a sense of dread, or fearing the worst. feeling like the world is speeding up or slowing down. feeling like other people can see you’re anxious and are looking at you.

    3. What does anxiety do to a person?

    People with these disorders have feelings of fear and uncertainty that interfere with everyday activities and last for 6 months or more. Anxiety disorders can also raise your risk for other medical problems such as heart disease, diabetes, substance abuse, and depression.

    4. Does anxiety ever go away?

    Typical anxiety can last for days, or at least until you’ve dealt with whatever is making you anxious, but anxiety disorders can persist for months or years without relief. Often, the only way to control anxiety is through professional treatment.

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  • Nursing Care Plans For Anemia Plus Interventions – Best Nursing Care Plans(2022)

    This article discusses Anemia Nursing Diagnosis, causes, symptoms, preventions, care plans, and interventions.

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    Disclaimer: The information presented in this article is not medical advice; it is meant to act as a quick guide to nursing students for learning purposes only and should not be applied without an approved physician’s consent. Please consult a registered doctor in case you’re looking for medical advice.

    Introduction

    Anemia is defined as a low number of red blood cells. Anemia is reported as low hemoglobin or hematocrit in a routine blood test. Hemoglobin is the main protein in your red blood cells. It carries oxygen and delivers it throughout your body. If you have anemia, your hemoglobin level will be low too. If it is low enough, your tissues or organs may not get enough oxygen. Symptoms of anemia — like fatigue or shortness of breath — happen because your organs aren’t getting what they need to work the way they should.

    Women, young children, and people with long-term diseases are more likely to have anemia. Important things to remember are:

    • Certain forms of anemia are passed down through your genes, and infants may have it from birth.
    • Women are at risk of iron deficiency anemia because of blood loss from their periods and higher blood supply demands during pregnancy.
    • Older adults have a greater risk of anemia because they are more likely to have kidney disease or other chronic medical conditions.

    Symptoms of Anemia

    The signs of anemia can be so mild that you might not even notice them. As your blood cells decrease, symptoms often develop at a certain point. Depending on the cause of the anemia, symptoms may include:

    1. Dizziness, lightheadedness, or feeling like you are about to pass out
    2. Fast or unusual heartbeat
    3. Headache
    4. Pain, including in your bones, chest, belly, and joints
    5. Problems with growth for children and teens
    6. Shortness of breath
    7. Skin that’s pale or yellow
    8. Cold hands and feet
    9. Tiredness or weakness

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    Types of Anemia Based on Cause

    There are more than 400 types of anemia, and they’re divided into three groups:

    1. Anemia caused by blood loss
    2. Anemia caused by decreased or faulty red blood cell production
    3. Anemia caused by the destruction of red blood cells

    Anemia Caused by Blood Loss

    You can lose red blood cells through bleeding. This can happen slowly over a long period of time, and you might not notice. Causes can include:

    1. Gastrointestinal conditions such as ulcers, hemorrhoids, gastritis (inflammation of your stomach), and cancer
    2. Non-steroidal anti-inflammatory drugs (NSAIDs) such as aspirin or ibuprofen, which can cause ulcers and gastritis
    3. A woman’s period, especially if you have heavy menstruation (or heavy period). This can be associated with fibroids.
    4. Post-trauma or post-surgery as well.

    Anemia Caused by Decreased or Faulty Red Blood Cell Production

    With this type of anemia, your body may not create enough blood cells, or they may not work the way they should. This can happen because there’s something wrong with your red blood cells or because you don’t have enough minerals and vitamins for your red blood cells to form normally. Conditions associated with these causes of anemia include:

    1. Bone marrow and stem cell problems
    2. Iron-deficiency anemia
    3. Sickle cell anemia
    4. Vitamin-deficiency anemia, specifically b12 or folate

    Bone marrow and stem cell problems

    Bone marrow and stem cell problems may keep your body from producing enough red blood cells. Some of the stem cells in the marrow that’s in the center of your bones will develop into red blood cells. If there aren’t enough stem cells, if they don’t work right, or if they’re replaced by other cells such as cancer cells, you might get anemia. Anemia caused by bone marrow or stem cell problems includes:

    Aplastic anemia happens when you don’t have enough stem cells or have none at all. You might get aplastic anemia because of your genes or because your bone marrow was injured by medications, radiation, chemotherapy, or infection. Other malignancies that commonly affect the bone marrow include multiple myeloma or leukemia. Sometimes, there’s no clear cause of aplastic anemia.

    Lead poisoning. Lead is toxic to your bone marrow, causing you to have fewer red blood cells. Lead poisoning can happen when adults come into contact with lead at work, for example, or if children eat lead paint chips. You can also get it if your food comes into contact with some types of pottery that aren’t glazed right.

    Thalassemia happens with a problem with hemoglobin formation (4 chains aren’t correctly formed). Patients with thalassemia make really small red blood cells though they can make enough of them to be asymptomatic, or it can be severe. It’s passed down in your genes and usually affects people of Mediterranean, African, Middle Eastern, and Southeast Asian descent. This condition can range from mild to life-threatening; the most severe form is called Cooley’s anemia.

    Iron-deficiency anemia

    Iron-deficiency anemia happens because you don’t have enough of the mineral iron in your body. Your bone marrow needs iron to make hemoglobin, the part of the red blood cell that takes oxygen to your organs. Iron-deficiency anemia can be caused by:

    • A diet without enough iron, especially in infants, children, teens, vegans, and vegetarians
    • Certain drugs, foods, and caffeinated drinks
    • Digestive conditions such as Crohn’s disease, or if you’ve had part of your stomach or small intestine removed
    • Donating blood often
    • Endurance training
    • Pregnancy and breastfeeding use up iron in your body
    • Women period
    • A common cause is chronic slow bleed, usually from a Gastrointestinal source.

    Sickle Cell Anemia

    Red blood cells, which are usually round, become crescent-shaped because of a gene problem. Anemia results when the red blood cells break down quickly, so oxygen doesn’t get to your organs. The crescent-shaped red blood cells can also get stuck in tiny blood vessels and cause pain.

    Vitamin deficiency Anemia

    Vitamin deficiency anemia can happen when you aren’t getting enough vitamin B12 and folate. You need these two vitamins to make red blood cells. This kind of anemia can be caused by:

    Dietary deficiency: If you eat little or no meat, you might not get enough vitamin B12. If you overcook vegetables or don’t eat enough of them, you might not get enough folate.

    Megaloblastic anemia: When you don’t get enough vitamin B12, folate, or both

    Pernicious anemia: When your body doesn’t absorb enough vitamin B12

    Other causes of vitamin deficiency include medications, alcohol abuse, and intestinal diseases such as tropical sprue.

    Anemia Caused by Destruction of Red Blood Cells

    When red blood cells are fragile and can’t handle the stress of traveling through your body, they may burst, causing what’s called hemolytic anemia. You might have this condition at birth, or it could come later. Sometimes, the causes of hemolytic anemia are unclear, but they can include:

    1. An attack by your immune system, as with lupus. This can happen to anyone, even a baby still in the womb or a newborn. That’s called hemolytic disease of the newborn.
    2. Conditions that can be passed down through your genes, such as sickle cell anemia, thalassemia, and thrombotic thrombocytopenic purpura (TTP)
    3. Enlarged spleen. This can, in rare cases, trap red blood cells and destroy them too early.
    4. Something that puts strain on your body, such as infections, drugs, snake or spider venom, or certain foods
    5. Toxins from advanced liver or kidney disease
    6. Vascular grafts, prosthetic heart valves, tumors, severe burns, being around certain chemicals, severe hypertension, and clotting disorders

    Risk Factors of Anemia

    These factors place you at increased risk of anemia:

    A diet lacking in certain vitamins and minerals. A diet consistently low in iron, vitamin B-12, folate, and copper increases your risk of anemia.

    Intestinal disorders. Having an intestinal disorder that affects the absorption of nutrients in the small intestine — such as Crohn’s disease and celiac disease — puts a person at risk of anemia.

    Menstruation. In general, women who haven’t had menopause have a greater risk of iron deficiency anemia than do men and postmenopausal women. Menstruation causes the loss of red blood cells.

    Pregnancy. Being pregnant and not taking a multivitamin with folic acid and iron increases your risk of anemia.

    Chronic conditions. If you have cancer, kidney failure, or another chronic condition, you could be at risk of anemia of chronic disease. These conditions can lead to a shortage of red blood cells.

    Slow, chronic blood loss from an ulcer or other source within your body can deplete your body’s store of iron, leading to iron deficiency anemia.

    Family history. If your family has a history of inherited anemia, such as sickle cell anemia, you also might be at increased risk of the condition.

    Other factors. A history of certain infections, blood diseases, and autoimmune disorders increases your risk of anemia. Alcoholism, exposure to toxic chemicals, and the use of some medications can affect red blood cell production and lead to anemia.

    Age. People over age 65 are at increased risk of anemia.

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    Diagnosis of Anemia

    A complete blood count (CBC) test will measure the red blood cells, hemoglobin, and other parts of the blood. The doctor will ask about family history and medical history after the CBC. They’ll probably do some tests, including:

    • Blood smear or differential to count your white blood cells, check the shape of your red blood cells and look for unusual cells
    • Reticulocyte count to check for immature red blood cells

    Complications of Anemia

    Left untreated, anemia can cause many health problems, such as:

    1. Extreme fatigue. Severe anemia can make you so tired that you can’t complete everyday tasks.
    2. Pregnancy complications. Pregnant women with folate deficiency anemia can be more likely to have complications, such as premature birth.
    3. Heart problems. Anemia can lead to a rapid or irregular heartbeat (arrhythmia). When you’re anemic, your heart pumps more blood to make up for the lack of oxygen in the blood. This can lead to an enlarged heart or heart failure.
    4. Death. Some inherited anemias, such as sickle cell anemia, can lead to life-threatening complications. Losing a lot of blood quickly results in acute, severe anemia and can be fatal. Among older people, anemia is associated with an increased risk of death.

    Prevention of Anemia

    Many types of anemia can’t be prevented. But you can avoid iron deficiency anemia and vitamin deficiency anemias by eating a diet that includes a variety of vitamins and minerals, including:

    Iron. Iron-rich foods include beef and other meats, beans, lentils, iron-fortified cereals, dark green leafy vegetables, and dried fruit.

    Folate. This nutrient, and its synthetic form folic acid, can be found in fruits and fruit juices, dark green leafy vegetables, green peas, kidney beans, peanuts, and enriched grain products, such as bread, cereal, pasta, and rice.

    Vitamin B-12. Foods rich in vitamin B-12 include meat, dairy products, fortified cereal, and soy products.

    Vitamin C. Foods rich in vitamin C include citrus fruits and juices, peppers, broccoli, tomatoes, melons, and strawberries. These also help increase iron absorption.

    Treatment of Anemia

    The treatment will depend on the type of anemia. There are a lot of causes, so there are also many treatments available.

    A patient with aplastic anemia might need medication, blood transfusions, or a bone marrow transplant.

    A patient with hemolytic anemia might need medication that will hold back the immune system.

    If it’s caused by blood loss, the patient might have surgery to find and fix the bleeding.

    If it is iron-deficiency anemia, the patient probably needs to take iron supplements and change diet.

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    Nursing Care Plans For Anemia
    Nursing Care Plans For Anemia

    Sickle cell anemia treatment includes painkillers, folic acid supplements, intermittent antibiotics, or oxygen therapy. Hydroxyurea (Droxia, Hydrea, Siklos) is often prescribed to decrease sickle cell pain crises (a complicated mechanism). The voxelator (Oxbryta) medication can help the red blood cells keep their proper shape. Crizanlizumab-tmca (Adakveo) can keep the blood cells from sticking together and blocking vessels. L-glutamine oral powder (Endari) can cut down on your hospital trips for pain and guard against a condition called acute chest syndrome.

    A patient has vitamin B12 or folate deficiency will be prescribed supplements.

    Thalassemia doesn’t usually need treatment, but if it is a severe case, the patient might need blood transfusions, a bone marrow transplant, or surgery.

    Nursing Care Plans for Anemia Based on Diagnosis

    Nursing Care Plan 1: Diagnosis – Fatigue

    Fatigue: An overwhelming, sustained sense of exhaustion and decreased physical and mental work capacity at the usual level.

    May be related to decreased hemoglobin and diminished oxygen-carrying capacity of the blood.

    Possibly evidenced by:

    1. Exertional discomfort or dyspnea.
    2. Inability to maintain usual level of physical activity.
    3. Increased rest requirements.
    4. Report of fatigue and lack of energy.
    5.  

    Desired Outcomes

    A patient will verbalize the use of energy conservation principles.

     A patient will verbalize reduction of fatigue, as evidenced by reports of increased energy and ability to perform desired activities.

    Nursing InterventionsRationale
    Assess the specific cause of fatigue.The specific cause of fatigue is due to tissue hypoxia from normocytic anemia; Other related medical problems can also compromise activity tolerance.
    Assess the  A patient’s ability to perform activities of daily living (ADLs) and the demands of daily living,Fatigue can limit the patient’s ability to participate in self-care and perform their role responsibilities in family and society, such as working outside the home.
    Assist the patient in planning and prioritizing activities of daily living (ADL).This will allow the patient to maximize their time for accomplishing important activities. Not all self-care and hygiene activities need to be completed in the morning. Likewise, not all housework needs to be completed in one day.
    Assist the patient in developing a schedule for daily activity and rest. Stress the importance of frequent rest periods.Energy reserves may be depleted unless the patient respects the body’s need for increased rest. A plan that balances periods of activity with rest periods can help the patient complete desired activities without adding fatigue levels.
    Monitor hemoglobin, hematocrit, RBC counts, and reticulocyte counts.Decreased RBC indexes are associated with the decreased oxygen-carrying capacity of the blood. It is critical to compare serial laboratory values to evaluate patient progression or deterioration and identify changes before they become life-threatening.
    Educate energy-conservation techniques. Patients and caregivers may need to learn skills for delegating tasks to others, setting priorities, and clustering care to use the available energy to complete desired activities. Organization and time management can help the patient conserve energy and reduce fatigue.
    Instruct the patient about medications that may stimulate RBC production in the bone marrow.Recombinant human erythropoietin, a hematological growth factor, increases hemoglobin and decreases the need for RBC transfusions.
    Provide supplemental oxygen therapy as needed.Oxygen saturation should be kept at 90% or greater.
    Anticipate the need for the transfusion of packed RBCs.Packed RBCs increase the oxygen-carrying capacity of the blood.
    Refer the patient and family to an occupational therapist.The occupational therapist can teach the patient about using assistive devices. The therapist also can help the patient and family evaluate the need for additional energy-conservation measures in the home setting.

    Nursing Care Plan 2: Diagnosis -Deficient Knowledge

    Deficient Knowledge: Absence or deficiency of cognitive information related to a specific topic.

    May be related to:

    • Complexity of treatment.
    • Lack of recall.
    • Lack of resources.
    • New condition or treatment.
    • Unfamiliarity with the disease condition.

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    Nursing Care Plans For Anemia
    Nursing Care Plans For Anemia

    Possibly evidenced by:

    • Inaccurate follow-through of instructions.
    • Questioning members of the health care team.
    • Verbalized inaccurate information.

    Desired Outcomes

    A patient will verbalize understanding of own disease and treatment plan.

    Nursing InterventionsRationale
    Assess current knowledge of the diagnosis, disease process, possible causative factors, and treatment.Determining the patient’s current knowledge and perceptions will facilitate the planning of individualized teaching. Patients may have a general understanding of anemia related to iron deficiency but limited knowledge of other types of anemia.
    Assess the patient’s and family’s understanding of the new medical vocabulary.Usually, people have a limited understanding of medical vocabulary, hence are not exposed to the language being used by the health care professionals.
    Explain the importance of the diagnostic procedures (such as complete blood count), bone marrow aspiration, and a possible referral to a hematologist.Diagnosing a type of anemia will be based on the changes in the RBC indexes and the findings in the bone marrow aspiration.
    Explain the hematological vocabulary and the functions of blood elements, such as white blood cells, red blood cells, and platelets.Patients usually have a basic knowledge of the hematological system.
    Instruct patient to avoid known risk factors.Causative factors such as alcoholism, exposure to toxic chemicals, dietary deficiencies, and the use of some medications can affect red blood cell production and lead to anemia.
    For aplastic anemia:
    Explain that blood transfusions from prospective marrow donors should be avoided.Histocompatibility antigens may lead to donor marrow rejection.
    Explain the need for rapid human leukocyte antigen (HLA) typing.The human leukocyte antigen (HLA) test, also known as HLA typing or tissue typing, identifies antigens on the white blood cells (WBCs) that determine tissue compatibility for organ transplantation.
    Explain that immunosuppressive therapy is the treatment of choice in patients without HLA-matched donors and older than 40 years of age.The treatment of choice in patients without HLA-matched donors is immunosuppression with granulocyte-macrophage-colony-stimulating factors, cyclophosphamide, anti-thymocyte globulin, and cyclosporine.
    Explain that allogeneic hematopoietic stem cell transplantation is the standard treatment for patients younger than 40 years old who have HLA-identical related donors.Hematopoietic stem cell transplantation (HCT) effectively treats many life-threatening diseases. Usually, a  patient’s own (autologous) cells or (allogeneic) cells from a donor with the same genetic makeup are used.
    Explain the potential complications associated with immunosuppressive therapy.
    Acute graft-versus-host disease (GVHD).The earliest symptoms include a red maculopapular rash, dryness of the eye, abdominal pain, and jaundice.
    Chronic GVHD. Patients with Chronic GVHD may present with a variety of symptoms. Skin rash and mouth sores are among the common initial signs of the disease. The rash is often slightly raised and may be itchy.
    Rejection of donor marrow.Rejection happens when a sensitization to histocompatibility antigens is acquired during previous blood transfusions and carries a high mortality rate. Conditioning regimens using cyclophosphamide (Cytoxan) and total lymphoid irradiation show a decrease in the risk for graft failure.
    For nutritional deficiency anemia:
    Explain the importance of vitamin B12 replacement.Vitamin B12 injections are used to treat this vitamin’s low levels (deficiency). They are given monthly for the remainder of the patient’s life. It elevates levels of vitamin B12, a deficiency caused by a lack of intrinsic factors that impair vitamin absorption.
    Educate the patient and the family regarding food rich in iron, folic acid, and vitamin B12.A balanced diet that includes a variety of foods from each food group usually contains essential nutrients needed to promote RBC formation. Patients need to have an adequate intake of dark-green leafy vegetables animal products, including fish, meat, poultry, eggs, milk, and fortified breakfast cereals.
    Educate the patient and the family regarding replacement therapy with folic acid and iron.The dosage and frequency of administration will depend on the severity of anemia. Iron supplements are given orally with meals to prevent a gastric upset. Intramuscular injections are also available given via the Z-track method to prevent leakage of the solution in the subcutaneous tissue along the needle tract. While folic acid is given orally with a full glass of water.
    For blood loss anemia:
    Instruct the patient about certain medications that may stimulate RBC production in the bone marrow.Recombinant human erythropoietin, a hematological factor, elevates hemoglobin levels and decreases the need for a transfusion of packed RBC.
    Explain that a transfusion of packed RBCs may be needed.One unit of packed RBC raises the hemoglobin level by 1 g/dL.

    Nursing Care Plan 3: Diagnosis – Risk for Infection

    Risk for Infection: At increased risk for being invaded by pathogenic organisms.

    Risk Factors

    • Bone marrow malfunction.
    • Marrow replacement with fat in aplastic anemia.

    Desired Outcomes

    A patient will have a reduced risk of infection as evidenced by an absence of fever, normal white blood cell count, and implementation of preventive measures such as proper handwashing.

    A patient will have vital signs within the normal limit.

    Nursing InterventionsRationale
    Assess for local or systemic signs of infection, such as fever, chills, swelling, pain, and body malaise.Opportunistic infections can easily develop, especially in immunocompromised patients.
    Monitor WBC count.A low white blood cell count (leukopenia) is a decrease in disease-fighting cells (leukocytes) in your blood. In general, for adults, a count lower than 4,000 white blood cells per microliter of blood is considered a low white blood cell count.
    Instruct the patient to report signs and symptoms of infection immediately.A simple fever is significant enough not to pay attention to. A need for antibiotic therapy may be indicated.
    Anticipate the need for an antibiotic, antiviral, and antifungal therapy.These agents are effective against killing an infection.
    Instruct the patient to avoid contact with people with existing infections.These can be a source of infection for the immunocompromised patient. Children 12 years of age or younger are at risk because they can be carriers of infection, especially upper respiratory infection.
    If the patient is hospitalized, provide a private room for protective isolation.Environmental changes may be important if the absolute neutrophil count is less than 500/mm3. Protective isolation precautions may include placing the patient in a private room, limiting visitors, and having all people who encounter the patient use mask, gowns, and gloves. These patients are at significant risk for infection.
    Instruct the patient to avoid eating raw fruits and vegetables and uncooked meat.These food items can harbor bacteria. A low-bacterial diet protects the patient from exposure to pathogens.
    Stress the importance of daily hygiene, mouth care, and perineal care.These preventive measures help avoid skin breakdown and lessen the risk of infection.
    Teach the patient and visitors proper handwashing.Practicing hand hygiene is an effective way to prevent infections. Washing hands can prevent the spread of germs, including those that are resistant to antibiotics.
    Administer WBC growth factor to stimulate the production of neutrophils.Colony-stimulating factors (CSFs), long-acting pegfilgrastim, filgrastim are medications used to stimulate the production of infection-fighting white blood cells.

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    Nursing Care Plans For Anemia
    Nursing Care Plans For Anemia

    Nursing Care Plan 4: Diagnosis – Risk for Bleeding

    Risk for Bleeding: At risk for a decrease in blood volume that may compromise health.

    Risk Factors

    • Bone marrow malfunction.
    • Marrow replacement with fat in aplastic anemia.

    Desired Outcomes

    A patient will have a reduced risk for bleeding, as evidenced by normal or adequate platelet levels and absence of bruises and petechiae.

    Nursing InterventionsRationale
    Assess the skin for bruises and petechiae.Bruises and petechiae are usually evident when the platelet count drops to 20,000 mm3.
    Assess for any frank bleeding from the nose, gums, vagina, or urinary or gastrointestinal tract.The early assessment facilitates immediate treatment. These sites are most common for spontaneous bleeding.
    Monitor platelet count.A low platelet count or thrombocytopenia is caused by a bone marrow malfunction resulting from nutritional deficiencies, drugs, certain viral causes, or aplastic anemia. The risk for bleeding is increased as platelet count is decreased.
    Monitor stool (guaiac) and urine(Hemastix) for occult blood.These tests help identify the site of bleeding.
    Consolidate laboratory blood sampling test.Repeated blood sampling over time can lead to anemia. Consolidation minimizes the number of venipunctures and optimizes blood volume.
    Instruct the patient in dietary modifications to reduce constipation.Eating a diet high in fiber and drinking a lot of fluids to avoid constipation or using a stool softener and other laxatives as prescribed if having difficulty passing stool.
    Instruct the patient about bleeding precautions. Instruct the patient to use an electric shaver, not a razor. Use a soft toothbrush when brushing the teeth. Use pads instead of tampons. Avoid rectal procedures such as suppositories, enemas, and rectal temperature readings. Using a water-based lubricant during sexual intercourse to reduce friction (KY Jelly or Astroglide)Once the patient’s platelet count drops to 50,000mm3, bleeding precaution should be instituted immediately to avoid the risk of spontaneous bleeding.
    Anticipate the need for a platelet transfusion once the platelet count drops to a very low value.Platelet replacement may be required to reduce the risk of bleeding. Premedication with antihistamine and antipyretics reduces transfusion reaction side effects.

    References

    Related FAQs

    1. What is the main cause of anemia?

    The most common cause of anemia is low levels of iron in the body. This type of anemia is called iron-deficiency anemia. Your body needs a certain amount of iron to make hemoglobin, the substance that moves oxygen throughout your body.

    2. What are 5 symptoms of anemia?

    Symptoms

    • Fatigue.
    • Weakness.
    • Pale or yellowish skin.
    • Irregular heartbeats.
    • Shortness of breath.
    • Dizziness or lightheadedness.
    • Chest pain.
    • Cold hands and feet.

    3. What are the 3 main causes of anemia?

    Hemoglobin is an iron-rich protein that gives the red color to blood. It carries oxygen from the lungs to the rest of the body. Anemia has three main causes: blood loss, lack of red blood cell production, and high rates of red blood cell destruction.

    4. Can anaemia be cured?

    There’s no specific treatment for this type of anemia. Doctors focus on treating the underlying disease. If symptoms become severe, a blood transfusion or injections of a synthetic hormone normally produced by your kidneys (erythropoietin) might help stimulate red blood cell production and ease fatigue.

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    Nursing Care Plans For Anemia
    Nursing Care Plans For Anemia

    5. What foods to avoid if you are anemic?

    • tea and coffee.
    • milk and some dairy products.
    • foods that contain tannins, such as grapes, corn, and sorghum.
    • foods that contain phytates or phytic acid, such as brown rice and whole-grain wheat products.
    • foods that contain oxalic acid, such as peanuts, parsley, and chocolate.

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  • GUIDELINES FOR WRITING HISTORY AND PHYSICALS PAPER – Best Guidelines(2022)

    This article covers the GUIDELINES FOR WRITING HISTORY AND PHYSICALS PAPER.

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    GUIDELINES FOR WRITING HISTORY AND PHYSICALS PAPER

    Written documentation for clinical management of patients within health care settings usually includes one or more of the following components:

    • Problem Statement (Chief Complaint)
    • Subjective   (History)
    • Objective   (Physical Exam/Diagnostics)
    • Assessment (Diagnoses)
    • Plan (Orders)
    • Rationale (Clinical Decision Making)

    Expertise and quality in clinical write-ups is somewhat of an art form that develops over time as the student/practitioner gains practice and professional experience. In general, students are encouraged to review patient charts, reading as many H/Ps, progress notes, and consult reports, as possible. In so doing, one gains insight into a variety of writing styles and methods of conveying clinical information.

    Frequently, these documents were written by persons with extensive clinical experience who have developed succinct and precise clinical writing styles. Ultimately, each individual will incorporate input from a variety of sources and synthesize a clinical writing style that is both professionally functional and unique to that person.

    The following sections will address the specifics for obtaining information and writing each of these components. Numerous examples are given throughout. At the end of this discussion, an example of a SOAP note for a particular clinical problem is presented. For purposes of comparison, an example of a HISTORY AND PHYSICAL (H/P) for that same problem is also provided. Note that the SOAP contains only that information that is relevant to evaluating the problem at hand while the H/P is more a thorough database and contains all information, whether or not it is relevant to the patients’ problem or chief complaint (CC ).

    Whether the practitioner writes a SOAP note or a History and Physical will depend on the particular setting wherein the problem is being addressed. Usually, a H/P is done for an initial visit with a client at a particular outpatient health care facility or whenever the client is admitted to an in-patient facility.

    Frequently, a H/P is done annually at a given facility while any interim visits for particular health care problems are documented as SOAP notes.

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    Specifically for in-patient settings, after an admission H/P is done, SOAP notes detail the regular follow-up visits by various health care professionals. Often they comprise the format for the “Progress Notes” and address the status of particular problems for which the patient has been admitted.

    A variety of different professionals practicing in a given institution might be writing SOAP notes on a patient. Each will address the problem(s) from a wide variety of professional perspectives.  The dietician may address the patient’s compliance or comprehension of an ADA diet and document the visit in the form of a SOAP note.

    The podiatrist may be charting the same patient’s diabetic foot ulcer. The cardiologist may be addressing the patient’s status with respect to angina or S/P MI. The intern may be addressing the overall management of the patient in the particular unit. Each would likely write a SOAP note which documents his/her visit and summarizes the findings.

    The frequency of visits and writing SOAP notes will be a function of how often the particular services in question are needed. The intern assigned to the floor or service may chart daily or even more frequently if problems/complications arise. The podiatrist may make bi-weekly visits and chart accordingly.

    The dietician may see the patient only once if the hospital stay is short. In the case of the outpatient, a SOAP note is generated for each contact with the health care facility.

    PROBLEM STATEMENT

    STATEMENT OF PROBLEM OR PURPOSE OF VISIT: This statement details the purpose of the visit. It may or may not be the same as the Chief Complaint (CC). For example, the problem statement may be “Angina/R/O MI” but the patient’s CC may have been “I feel dizzy and sweaty and I have pain running down my arm and in my jaw.” In other cases, the problem statement and the CC will be identical.  

    In the example presented at the end of this discussion, the problem statement is “Abdominal pain” and the CC is “I have abdominal pain and it is quite severe.”

    Often, but not always, particular problems have been previously assigned a number on a problem list that appears on the patient’s office chart or hospital record. Any time someone charts on a particular problem in the Progress Notes, that person lists the problem to be addressed (and perhaps its number) just before writing the SOAP note. Examples of problem statements are as follows

    • Chest pain
    • Abdominal pain
    • Hypertension
    • College physical  or annual  Pap and Pelvic

    SUBJECTIVE OR HISTORY: This portion of the SOAP note (or H/P) includes a statement, preferably in the patient’s own words regarding the chief complaint (CC) which details why the patient has presented to the health care facility – i.e. why is he/she here?

    • “I have abdominal pain”
    • Pt here for routine f/u HTN
    • Pt requests physical for high school soccer team

    For SOAP notes, all other pertinent information reported by the patient (or significant others) should be included in this section.

    The information should detail what the patient has told the health care provider, and include the pertinent information to work up the particular complaint. It should include SYMPTOM ANALYSIS, PERTINENT POSITIVES, PERTINENT NEGATIVES, AND ROS FOR THE PARTICULAR SYSTEM INVOLVE D. If one is writing this subjective portion would follow the standard format for writing a patient history.

    Relevant information that the patient (or family, etc.) reports should be included. Certain information may appear in either the subjective or objective portion of the SOAP or H/P depending on the source of the information.   For example, if the patient tells the interviewer that he had a cardiac cath at XYZ hospital and that it has revealed thus and so, then this information belongs under SUBJECTIVE.

    Patient reports that he had a cardiac cath at NYU Medical Center in 1994 after which ” they told me that 3 of my vessels were clogged.”

    If the health care provider has read the actual cath report or has spoken with the cardiologist/other professional staff, then what is essentially the same information would appear under the OBJECTIVE component of the note.

    Cardiac Cath done in March of 94 at NYU Medical Center reveals 3 vessel disease with 80% occlusion of etc.

    In addition to the problem at hand, SOAP notes generally address important past medical history, relevant family history, and social history, albeit briefly so. Important aspects of the medical history (e.g. diabetes, HTN, s/p MI, s/p pacemaker, etc.) have implications for any and all subsequent health care problems and should be at least mentioned in the note. THERE IS NEVER AN EXCUSE TO NOT TO ASK AND DOCUMENT INFO RE: MEDICATIONS (RX/OTC), ALLERGIES, OR IMPORTANT MEDICAL CONDITIONS.  The reference need not be detailed and can be brief but it should be included.

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    • “a known diabetic on oral hypoglycemics”
    • “hypertension on Vasotec  x 4  years; suboptimal  control”
    • “Denies history of diabetes, HTN, asthma, or CA.”

    Even the most trivial complaints warrant documenting this type of information. Would you want to give the patient on Hytrin for BPH or a patient who has been treated for cataracts a seemly harmless antihistamine/decongestant preparation for his cold?

    How about the person who reports an allergy to prednisone? Should you RX a Medrol Dosepak for his poison ivy? IF YO U D ON’T AS K, YOU WON’T KNOW AND IN A COURT OF LAW, IF YOU DID NOT DOCUMENT IT, YOU DID NOT DO IT!

    The following is an example of the SUBJECTIVE portion of a SOAP note. It includes only that information that is relevant to the problem at hand. Essentially the same information (up to PMH) would comprise the HPI in a H/P for this same problem.

    PROBLEM # 1: Abdominal Pain

    SUBJECTIVE: 24-year-old female; was in her usual state of health until 3 days ago when she began to experience abdominal pain described as “severe” and sharp/knife-like. Localized to lower abdominal regions; more intense on the right side.

    Worsens w movement; somewhat relieved by Advil, but not markedly so. Pain gradual in onset; worsening over the last few days. Became quite severe last evening, keeping her awake most of the night. Uncertain re: fevers; reports chills last evening and sweats after taking Advil.

    Sexually active, new partner beginning 4 months ago. He told her the relationship is monogamous; she “hopes it is.” Previous sexual partner over 1 year ago. New partner irregularly uses condoms; “He gets mad when I ask him to and says I don’t trust him.” Did not press the issue because “I am afraid of losing him.” No other contraception; LMP 19 days ago.

    Vaginal discharge which was “a little yellowish” approx 10 or 12 days ago; assumed it was yeast and self- medicated w OTC G yn-Lotrimin. Discharge persisted but was ignored because it was “only a little.”

    Denies burning, pain, pruritus, or swelling/redness to the vulva. Denies dysuria, frequency or urgency.  No previous STDs; Heterosexual w 4 previous sexual partners; never tested for HIV. New partner heterosexual w number of previous partners unknown.

    G1PO, 1 elective AB 4 years ago. Menarche age 13, cycles q 28-30, flow: 5-6 days. Mild dysmenorrhea; responds to Advil. Denies excessive bleed, clots, or unusual discharge prior to this episode; no frequent yeast infections.   Last PA P 2 years ago and normal.   No SBE; is “not sure how.”

    PMH: overall unremarkable; occasional colds/flu, usual childhood illnesses. Had 2nd MMR on entering college;? tetanus booster. Never initiated hepatitis series. Denies diabetes, HTN, cancer or asthma.

    Denies any depression or counseling. Surgeries: 1 TOP; otherwise non-contributory. Previous injuries, accidents and hospitalizations: non-contributory.

    FH: 1 sister w ectopic and question of STD; cousin w endometriosis; otherwise non-contributory.

    SH: college student; lives in dorm. Active in school and extracurricular activities; works part-time at the deli. Sexually active as per HPI. Non-smoker, ocas ETOH on w/e, no hx drug abuse. Family life stable and unremarkable.

    ALLERGIES: NKDA

    MEDS: occasional Advil, takes vitamins

    OBJECTIVE

    OBJECTIVE OR PHYSICAL ASSESSMENT: This section should include information obtained via physical exam, laboratory analysis, XRAYS, professional consults, etc. IT SHOULD NOT INCLUDE ANY INFOR MA TION W HICH THE PATIENT HAS TOLD YOU. That information belongs in the SUBJECTIVE. It may, however, include observations that you have made while interviewing the patient.

    “The patient was tearful and somewhat reticent to give inform ation during the interview.”

    For a HISTORY AND PHYSICAL, the OBJECTIVE would be the complete physical exam. It would be written following the standard format and would include any additional information available (lab reports, XRAY S, etc).  

    For a SOAP note, the OBJECTIVE would include all of the information necessary to evaluate the particular problem in question. AS A GENERAL RULE, THE PHYSICAL EXAM FINDINGS INCLUDED IN THIS SECTION WOULD BE THE VITAL SIGNS, HEIGHT/WT, GENERAL SURVEY, HEART, LU NG S AND WHATEVER ADDITIONAL SYSTEMS ARE RELEVANT TO THE PROB LEM. PERTINENT LAB ORA TORY DATA, XRAYS, CONSULT REPORTS, ETC. would be included.

    For the previously described patient with abdominal pain, the OBJECTIVE would be as follows:

    VS: 100/68, 102.5, 110, 26, WT 110, HT 5’2″

    Gen: AO X3 , WDW N female who appears moderately ill looking at this tim e. Repositions on table with obvious discomfort. Tearful, and somewhat reticent to give information during the interview.

    Heart: S1 >S 2 at apex, RRR without murmurs, clicks or gallops, pulses 2+/equal bilaterally Chest: A/P not inc; lungs: resonant/clear

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    Abdomen: Flat w RLQ scar noted; otherwise unremarkable to inspection w normoactive bowel sounds heard in all 4 quadrants.   Tympanic percussion note throughout.   Liver span: 9 cm RM CL, 5 cm RMSL w no splenic dullness noted at 10 ICS-LAAL. Diffusely tender to palpation w marked tenderness to RLQ. The abdomen is without organomegaly or abdominal masses noted. No lateral pulsation to aortic region; no CVA tenderness.

    Pelvic exam: external genitalia WNL/without lesions, speculum exam reveals a yellow purulent discharge from the cervical os; bimanual exam elicits cervical motion tenderness and a right adnexal mass.   The region is exquisitely tender to palpation. Left adnexal region overall unremarkable: non-tender; no structures palpated. Uterus is retroflexed and of normal size and consistency. Rectal confirms vaginal, stool guaiac negative.

    Diagnostics: wet mount show numerous polys to the cervical discharge; urine dip is negative; white count 13 .6 w prominent shift to left; HCG neg.

    While not an absolute rule, SOAP notes usually include at least a brief mention of the heart and lungs, along with the other relevant systems.  Excluding the heart/lungs would be the exception and not the rule, and, in general, is not a good practice.

    One could make an argument that a visit for poison ivy on a 15-year-old who has had many previous visits would not mandate a heart or lung exam. Had that same 15 year old been a smoker who “forgot” to mention that he had a dry cough for the last 4 weeks and subsequently was found to have mycoplasma pneumonia, giving him a Medrol Dosepak (which could exacerbate bacterial infections), would be less than desirable treatment his self-limiting dermatitis. A 30-second auscultation of the lungs might well have revealed crackles, a strong clue to the diagnosis.

    Even worse, what if this previously healthy 15-year-old, “nice kid” has a new onset murmur secondary to SBE which he contracted via secretly using IV heroin. He thought he was “safe” because he “only shares needles with people I know.” Three days later, he is admitted to the ICU with a septic pulmonary embolism.  

    Would you like to explain to the lawyer hired by the parents why you saw the patient in the

    office 3 days earlier, charged the parents $54 for an office visit, and never noticed that he had a new 3 /6 systolic murmur; a murmur which would have taken 15 seconds to find?

    Regarding, the example of the patient with abdominal pain, if the chief complaint had been, instead, chest pain or SOB, the exam of the cardiac and pulmonary system would have been a great deal more detailed and the pelvic exam would not likely be relevant.

    Obviously, the diagnostics would be much different, as well. Similarly, had the patient been a known COPD, the pulmonary exam would be a great deal more detailed EVEN IF the complaint were still for abdominal pain. Moreover, if the log were a H/P, every system would be examined in detail, whether or not it was relevant to the chief complaint.

    As much as possible use medical terminology when describing objective findings. The patient does not “appear to have a red rash to his forearm.” Rather, he has a “a 4 x 6 cm, irregularly sharped lesion comprised of scaly oval plaques on an erythematous base, over the ulnar aspect of the forearm.”  

    Instead of noting simply that the patient “appears to be depressed,” describe his behavior: “He has flat affect during the history and averts his eyes, rarely looking at the interviewer.”

    ASSESSMENT

    ASSESSMENT:   Assessments are DIAG NO SE S, whether that diagnosis is a medical or nursing diagnosis. In general, the former is preferred and expected. The student should write, for example

    1.     Bronchitis with underlying history of COPD (or AEC B)

    2.   Dehydration secondary to protracted vomiting

    3.   Diuretic therapy R/O hypokalemia

    4.   Unstable angina

    DO NOT use “nursing diagnoses” which have been designed to address medical conditions but which have been worded carefully so as to “not make a medical diagnosis.”  WHERE A MEDICAL DIAG NO SIS IS CALLED FOR, USE ONE.  Do not, for example, use “Alteration in fluid and electrolyte imbalance related to decreased fluid intake” when diagnosing a patient who is dehydrated.   “Dehydration secondary to ” (whatever is the reason) is the appropriate way to diagnose that patient. 

    Similarly, do not write   “Alteration in comfort related to ……” when what you mean is that the patient has pain. If the student’s preceptor is a physician he/she may regard the student who presents such a diagnosis as having just landed in from Mars, or at least, somewhere out in the ozone layer. If one’s preceptor is a nurse practitioner, he/she may need Maalox to deal with the unpleasant flashback from nursing school.

    If the patient has post-op pain or pain secondary to whatever cause, simply state it as such. As a nurse practitioner, it is perfectly acceptable and, in fact, expected that we use “medical” diagnoses. Recall, that when the student graduates from the program, he/she will be expected to function as a nurse practitioner with a relatively high level of function. If the employer/agency wanted an R.N., he/she/it would have hired one.

    Certain nursing diagnoses are quite useful, acceptable and may certainly be included, where applicable. “Nursing” diagnoses are particularly useful for many psycho-social situations e.g. “Alteration in coping secondary dysfunctional family dynamics” or “Grieving” or “self-care deficit” etc. and should be included where applicable.

    When writing the objective findings, avoid ambiguity or terms like “seems to,” “appears to have,” etc. The patient does not “seem to have scabies” or “appear to have angina.”

    If the patient has angina (or scabies), definitively diagnose it and write a plan which reflects the proper treatment.   Where   the diagnosis is unclear, use the terminology “rule out” e.g. “R /O angina.” In this case, the plan addresses whatever is necessary to establish the diagnosis and initiate the proper treatment.

    Avoid the term “related to.”   The preferred term is “secondary to.”   Also, avoid the term “suffers from.” What exactly is “suffering” and how exactly does one “suffer from” i.e. angina, a UTI, COPD.  It is preferable to write that “he has been previously diagnosed with angina” or simply write that “the patient has angina.”

    Where the exact nature of the problem is unclear, use R/O diagnoses or “E.U.” where it refers to “etiology unknownn” i.e. “vesicular lesions E.U.; R/O contact dermatitis.”   One may also use the term “cannot rule out” i.e. “Migraine cannot rule out aneurysm” or “Cough cannot rule out pneumonia.”

    EXAMPLE: returning to our previous patient with the abdominal pain, the assessment (diagnoses) might include the following:

    1. PID probable gonorrhea r/o tuboovarian abscess
    2. Knowledge deficit:    SBE/sexual practice/GYN care
    3. R/O other STD

    Any rationale for making particular diagnoses or choosing particular treatment plans will included under a separate section labeled RATIONALE.

    A common area of confusion for nurse practitioner students when they are writing the “assessment” for soap notes is that they often include information that they had been previously taught to include as a part of their “nursing assessment.” For purposes of SOAP notes, information previously gathered as part of a “nursing assessment – subjective and objective data – now belongs in the respective subjective and objective sections of the SOAP note.

    The assessment section is strictly limited to diagnoses.

    PLAN

    PLAN: The plan can be thought of as the steps necessary to address, solve or treat the problem.

    Sometimes the plan is synonymous with the orders. It need not be so. The plan is just that: a proposed course of action. Not infrequently the plan includes a rationale for the particular course of action which has been chosen.

    This rationale can be included in a separate section or it can be integrated with the plan.

    Usually, the former approach tends to be somewhat easier, especially for the student. Specific details and examples concerning the writing rationale will be addressed in the following section.

    Writing the Plan is usually quite straightforward. Continuing with the example of the patient with the abdominal pain the PLAN would be as follows:

    PLAN

    1. Admit to Dr. Brown’s person’s service
    2. VS: q 8h
    3. NPO
    4. ACTIVITY: BRP
    5. IV: D545NS at 125/hr
    6. Cervical culture: routine c/s, GC, chlamydia:   DONE in office
    7. CBC, SMAC drawn in office; U/A, HCG done in office
    8. Blood work A.M.: VDRL, Hepatitis B profile, HIV w consent
    9. MEDS:
    10. Clindamycin 600 mg IVSS q 6h
    11. Gentamycin 80 mg IVSS q 8h
    12. Augmentin 500 mg IVSS q 8h
    13. Pelvic u/s: STAT
    14. GYN consult: STAT
    15. Anticipate counseling/teaching on discharge
    16. SBE
    17. Safe sex
    18. Contraception
    19. Yeast infections/O TC tx

    Clearly the plan directs the approach to care of the patient or treating the problem at hand.  

    The plan should address the “whole picture” i.e. include what is anticipated to be done as well as that which will be done immediately. FOR OUTPATIENTS, IT SHOULD ALWAYS SPECIFY A TIME WHEN THE PATIENT WILL BE FOLLOWED UP.

    Example: Return to clinic in 3 weeks for reevaluation. To call sooner if there are problems in the interim.

    Example: Will f/u HTN q 3-4 months; patient to schedule appointment. Notify sooner for problems.

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    GUIDELINES FOR WRITING HISTORY AND PHYSICALS PAPER
    GUIDELINES FOR WRITING HISTORY AND PHYSICALS PAPER

    RATIONALE

    RATIONALE: The plan and rationale would tend to go “hand and hand.” The PLAN specifies proposed treatments for particular diagnoses while the RATIONALE details the “justification” for the particular approach chosen.   For example, the rationale might explain why the practitioner believes the headache for a given patient might be caused by an aneurysm and warrants a CAT scan to rule out an aneurysm.

    As another example, the rationale would address why the practitioner believes the cough could be pneumonia and is ordering a CXR. Obviously not every headache warrants a CAT and not every cough needs a radiograph.  

    The rationale would address why it is so for a particular case.

    FOR PURPOSES OF THIS COURSE, RATIONALE SHOULD BE INCLUDED IN ALL CLINICAL LOGS AND SHOULD INCLUDE AT LEAST O NE RE FERE NCE. 

    The RATIONALE should address the various components of the treatment plan.    In actual practice, the rationale is often not included and when included it may not be labeled as such. It may be as “Comment” or is sometimes called “Critical Decision Making.”

    Often, it is not included at all. The latter is particularly true if the plan is self-evident from the diagnoses (e.g. amoxicillin 250 tid x 10 days where the diagnosis the assessment is strep pharyngitis).

    When writing rationale, some element of judgmentt is appropriate. It is probably not necessary to include the rationale for that which is clearly self-evident. For example when ordering C BC to work up a diagnosis of “fatigue R/O anemia,” it is probably not necessary to justify ordering the CBC. Instead, the rationale could address the fact that anemia along with depression and whatever else is the part of the differential diagnosis for fatigue (according to XYZ reference) and should be considered for this particular patient in question.

    If a particular diagnosis is not being considered for a patient, i.e. it has been already ruled out, the rationale should indicate why that is so. For example, the rationale might discuss the reason why the practitioner has chosen the diagnosis of bacterial vaginosis and initiated treatment with Flagyl versus a diagnosis of candidiasis vulvovaginitis in which case, the appropriate treatment would be PO Diflucan or vaginal Terazol 7 cream .

    The following is an example of a PLAN and RATIONALE for 26-year-old, otherwise healthy male with repeat BP 140/110 who has been diagnosed with hypertension r/o secondary etiology.

    PLAN

    1. SMAC
    2. Random urine: U/A
    3. 24 hour urine: Total protein, creatinine clearance, VMA,  norepinephrine.   If elevated will consider nephrology consult.
    4. Renal Doppler.
    5. Lotensin 20 mg q d # 7 samples given
    6. Collection container and written instructions given. Initiate teaching re: HTN with specifics addressed and handouts given at this time.
    7. RTC in 1 week for recheck BP; will titrate medication accordingly. To notify sooner if any untoward effects in the interim.

    RATIONALE: secondary HTN would need to be ruled out due to client’s young age where the incidence of essential hypertension is low and the likelihood of secondary etiology is significant. In particular, would like to r/o renal or endocrine-based pathophysiology.

    Serum Na, K, creatinine and urine for protein were ordered for the assessment of renal function. If elevated, consider a sonogram for evidence of anatomic abnormalities and consultation with nephrology.

    ACE inhibitor therapy good choice for this age group due to low side effect profile and beneficial effect for HTN secondary to renal artery stenosis which would rank high in the differential diagnosis/etiology for a 26-year-old.

    For the above example, one would include a reference (APA format) which indicates wherein the student got that information i.e. Kelly, Harrison’s, etc. It is not necessary to include the rationale for that which is obvious i.e. why he was offered HTN teaching or handouts, etc.  Such rationale is reasonably self-evident.

    Recalling the example of the 24-year-old with abdominal pain, she was diagnosed with tubo-ovarian abscess and admitted on IV antibiotics. The rationale would address why the diagnosis was made, why she was admitted and why the particular antibiotics were chosen. It also addresses the issue of hepatitis.

    RATIONALE:  The elevated temp, white count and numerous polys in the discharge, in combination with the pelvic findings of cervical motion tenderness, clearly point to the diagnosis of PID (Rivlin, M. and R Martin, 1994 ).

    Moreover, the right adnexal mass and exquisite tenderness to this area would support a high index of suspicion for tubo-ovarian cyst, in which case we would anticipate surgical intervention with GYN consult ASAP.

    Antimicrobial therapy chosen, in accordance with standard practice, so as to provide adequate coverage for most of the polymicrobial flora encountered in these types of pelvic infections (Clark-Pearson and Yusoff Dawood, 1990).

    Clearly, this patient has profound knowledge deficits which need to be addressed prior to her discharge or on f/u office visit so as to avoid reoccurrence and/or other problems.

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    GUIDELINES FOR WRITING HISTORY AND PHYSICALS PAPER
    GUIDELINES FOR WRITING HISTORY AND PHYSICALS PAPER

    EXAMPLE OF HISTORY AND PHYSICAL

    For comparison purposes, the patient and CC are the same as the SOAP note presented in the preceding example. The H/P includes considerable more detail and information versus the SOAP note which provides only that information which is relevant to addresses the problem.

    CC:   “I have abdominal pain and it is very bad”

    HPI: 24-year-old female; was in her usual state of health until 3 days ago when she began to experience abdominal pain described as “severe” and sharp/knife-like. Localized to lower abdominal regions; more intense on the right side.   Worsens w movement; somewhat relieved by Advil, but not markedly so.   Pain gradual in onset; worsening over the last few days. Became quite severe last evening, keeping her awake most of the night. Uncertain re: fevers; reports chills last evening and sweats after taking Advil.

    Sexually active, new partner beginning 4 months ago. He told her the relationship is monogamous;  she “hopes it is.” Previous sexual partner over 1 year ago. New partner irregularly uses condoms; “He gets mad when I ask him to and says I don’t trust him.” Did not press the issue because “I am afraid of losing him.” No other contraception; LMP 19 days ago.

    Vaginal discharge which was “a little yellowish” approx 10 or 12 days ago; assumed it was yeast and self- medicated w OTC G yn-Lotrimin. Discharge persisted but was ignored because it was “only a little.” Denies burning, pain, pruritus or swelling/redness to the vulva. Denies dysuria, frequency or urgency.  No previous STDs; Heterosexual w 4 previous sexual partners; never tested for HIV. New partner heterosexual w number of previous partners unknown.

    G1PO, 1 elective AB 4 years ago. Menarche age 13, cycles q 28-30, flow: 5-6 days. Mild dysmenorrhea; responds to Advil. Denies excessive bleed, clots or unusual discharge prior to this episode; no frequent yeast infections.  Last PAP 2 years ago and normal.   No SBE; is “not sure how.”

    PAST MEDICAL HISTORY: overall unremarkable.  Occasional colds/flu.   Denies hx of diabetes, HTN, cancer, or asthma. Denies hx of depression or counseling.

    CHILDHOOD ILLNESSES AND IMMUNIZATIONS: usual childhood illnesses. Completed OPV/DTP series. Has had 2nd MMR on entering college; uncertain re last tetanus booster. Has never initiated hepatitis series.

    ACCIDENTS/INJURIES:  fell out of a tree as a child and fractured her collarbone.   MVA 5 years ago with a broken wrist and whip-lash injury; no residue deficits. Injured knee with surgical repair to ACL 3 years ago secondary to skiing accident.

    SURGICAL HISTORY:

    • AP at age 14
    • wisdom teeth extracted age 19
    • 1 elective TOP 2 years ago
    • ACL repair as per above

    HOSPITALIZATIONS:   for surgeries as described above.   One admission for bronchitis/pneumonia as a child.

    PSYCHIATRIC/SUBSTANCE ABUSE ADMISSIONS: none

    FAMILY HISTORY:

    • Father (58): HTN and angina
    • Mother: (57): NIDDM, overweight
    • 1 Sister (28): well
    • 1 Brother (22): depression on SSRI

    CANCER:

    • Pat grandfather (colon)
    • Maternal aunt (breast)
    • Maternal uncle (lung)

    Denies: cervical, ovarian, uterine

    CARDIAC/HTN:

    • Mat grandfather MI age 58, CVA age 70
    • Mat uncle: MI age 62, HTN
    • 2 pat uncles: HTN

    DIABETES:

    • Mat grandmother, 1 mat uncle ASTH MA: none

    GYN:

    • Mother: hysterectomy (52): DUB
    • Sister: ectopic, adhesions, ? PID
    • Cousin: endometriosis

    SOCIAL HISTORY: College senior (art major); active in school and extra-curricular activities to include theater group and yearbook. Lives in dorm; works part-time in deli. Heterosexual and sexually active with perceived monogamous boyfriend, as per HPI. Leisure activities include skiing, music, “hanging out with friends” and shopping. Life outlook normally positive. Goals: to secure employment as a curator of an art museum “in the city,” and to “get married and have children.” Non-smoker, ocas ETOH on w/e; no hx drug abuse. Caffeine intake: 2 -3 c/day, exercises at college health facility 2 -3 times per week. Fam ily life stable and unremarkable. Financially secure; support by parents.

    NUTRITIONAL HISTORY: eats “a lot of junk food” but also tries to watch her weight. Brings home food from the deli and dines mostly at college cafeteria. “Pigs out” frequently at Burger King, or local ice cream establishment.    No history of dysfunctional eating patterns.

    ALLERGIES: NKDA ; seasonal rhinitis, “might be” allergic to family cat who causes her to sneeze.

    MEDS: occasional Advil, takes vitamins.

    REVIEW OF SYSTEMS

    GENERAL: recent fever/chills as per HPI; denies recent wt changes, fatigue, weakness, night sweats, bleeding tendencies, easy bruising, anemia, transfusions, sickle cell, HIV testing

    SKIN: denies rashes, hives, eczema, lumps, sores, itching, dryness, color change, changes in moles/nevi, warts, changes in hair/nails, use of hair dye.

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    GUIDELINES FOR WRITING HISTORY AND PHYSICALS PAPER
    GUIDELINES FOR WRITING HISTORY AND PHYSICALS PAPER

    HEAD: denies lumps, vertigo, H/A, pain, fainting, trauma

    EYES: last eye exam 2 years ago, wears contacts; seasonal allergy w itching/red eyes.   Otherwise denies visual changes, pain, redness, excessive tearing, discharge, infections, double vision, glaucoma, cataracts, photophobia.

    EARS:   denies hearing impairment, use of hearing aid, tinnitus, vertigo, earaches, infection, discharge.

    NOSE/SINUS:  seasonal allergy/rhinitis w nasal congestion. Otherwise denies frequent URI, nasal congestion/stuffiness, obstruction, discharge, itching, hay fever, nosebleeds, sinus infection, trauma

    MOUTH/THROAT: last dental exam 8 months ago; 1 permanent bridge. Denies abscess, caries, gingivitis, bleeding, pus, or dentures. Denies sore tongue, frequent sore throat, hoarseness, voice changes, postnasal drip, oral thrush.

    NECK/NODES: “swollen glands” last year w episode of strep pharyngitis, denies goiter, pain or tenderness on movement, stiffness/limited ROM of neck.

    RESPIRATORY: denies cough, pain, dyspnea, sputum production. Denies hemoptysis, wheezing, asthma, bronchitis, emphysema, pneumonia, pleurisy, TB. Last PPD (neg) on entering college 3 years ago, never had CXR.

    BREAST: no SBE; denies known lumps, pain, tenderness, discharge or other changes. Never had mammogram.

    CARDIAC: denies disease/surgery, chest pain/discomfort, HTN, MI, palpitations, mumm ers, arrhythmias, rheumatic fever, dyspnea, DOE, orthopnea, PND, edema. Never had EKG, stress test or other cardiac testing.

    GI-UPPER: now anorexic since last evening; normally good appetite.   Denies gastritis, pain, ulcer, dysphagia, infections, heartburn, food intolerance, nausea, vomiting, regurgitation, hemoptysis, indigestion, excessive belching.

    GI-LOWER: See HPI; normally w/o abdominal pain.   Denies infections, frequent bowel movements, change in bowel habits, rectal bleeding, black tarry stools, hemorrhoids, constipation diarrhea, or excessive flatus. Stools normally formed, brown and q daily. Denies “pencil” stools,” infections, jaundice, liver/gallbladder/spleen, hepatitis, IBS,   Crohn’s.

    VASCULAR: denies pain in legs, calves/thighs/hips while walking.   Denies leg cramps, ulcers, varicose veins, thrombophlebitis,  clots in veins, swelling of legs, coolness/discoloration of extremity, loss of hair on legs, Raynaud’s phenomenon/disease.

    URINARY:    2 recent UTIs treated at college health center; Otherwise denies frequency, urgency, polyuria, nocturia, burning/pain on urination, hematuria. Denies hesitancy, decreased force of stream, incontinence, stones, flank pain, retention, color, unusual odor to urine.

    MUSCULOSKELETAL: sprained ankle twice last year. One episode of back pain 6 months ago from “carrying heavy books.” Otherwise denies muscle or joint pains/tenderness. Denies stiffness of muscles/joints, muscle cramps, arthritis, deformities, gout, backache, weakness, limitation to ROM, prosthesis.

    NEUROLOGICAL: denies LOC, CVA, epilepsy, fainting, blackouts, seizures, weakness, paralysis, numbness, tingling, tremors, involuntary movements, tics, loss of memory, disorientation, speech disorders, unsteady gait, loss of taste/smell.

    ENDO: denies thyroid disorders, heat/cold intolerance, excessive sweating, diabetes, excessive thirst/hunger, polyuria

    PSYCHIATRIC: denies mood changes, nervousness, depression, therapy/counseling, psychiatric disorders, hallucinations, psychiatric admissions.

    GEN\GYN: see HPI

    Related FAQs

    1. What should be included in a history and physical?

    Contents of a History and Physical Examination (H&P)

    The H&P shall consist of chief complaint, history of present illness, allergies and medications, relevant social and family history, past medical history, review of systems and physical examination, appropriate to the patient’s age.

    2. How do you write a patient medical history?

    How To Give A Good Medical History To Get Better Health Care

    1. Step 1: Include the important details of your current problem. Timing – When did your problem start?
    2. Step 2: Share your past medical history.
    3. Step 3: Include your social history.
    4. Step 4: Write out your questions and expectations.

    3. How do you present a patient’s history?

    You should begin every oral presentation with a brief one-liner that contains the patient’s name, age, relevant past medical history, and chief complaint. Remember that the chief complaint is why the patient sought medical care in his or her own words.

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    GUIDELINES FOR WRITING HISTORY AND PHYSICALS PAPER
    GUIDELINES FOR WRITING HISTORY AND PHYSICALS PAPER

    4. What are the timeliness requirements of the history and physical?

    When a history and physical (H & P) is completed within 30 days PRIOR TO inpatient admission or registration of the patient, an update is required within 24 hours AFTER the patient physically arrives for admission/registration but prior to surgery or a procedure requiring anesthesia services.

    Read More:

    https://customnursingassignments.com/hqs-620-o500-project-management-in-health-care/
    https://customnursingassignments.com/pediatric-patient-with-strep/

  • American Nurses Association (ANA) Code of Ethics-Disaster Response

    Watch the video and review the American Nurses Association (ANA) Code of Ethics to address the questions below in your discussion post this week.

    CUT AND PASTE THE BELOW WEB ADDRESS INTO THE BROWSER TO VIEW THE VIDEO:

     

    https://webapps.srm-app.net/CanvasContent/SF/WCU_NURS_431_OL_TEMPLATE/Presentations/NURS_431_Ethics_and_Legal_Issues_in_Disaster_Response/NURS_431_Ethics_and_Legal_Issues_in_Disaster_Response.html

     

    Review the American Nurses Association (ANA) Code of Ethics

    SEE ATTACHED FILE IN ATTACHMENTS

    Address the questions below in your discussion post this week:

    ·       Does the law require you to respond in disaster situations?

    ·       Do RNs have a contractual responsibility to respond in disaster situations?

    ·       Are you familiar with the laws in your state?

    Support your answers with evidence from at least 2 scholarly sources.