Question

Could you please do soap2 only cuz i already answered soap 1?

9:31 < Back SOAP Assignment #2.docx SOAP Assignment Case Stody: Cystic Fbresis ADMITTING HISTORY The patient had first been seen at the medical center at the age of 22 months, with a history of cougA fever. nose for 7 drys. His past history had revealed the peodaction of bulky, foul-smelling stools since infancy His first upper respiratory tract infection had developed at ape4 months, and he had had a chronic cough and imtemincnt wheezing ever since. He had had acute tonsillits beonchitis, and otitis media on three separate occasioes always treated with antibiotics. The peesent iliness had been diagnosed as "asthmatic bronchitis, and the pati had been Because the so-called Teonchnis had not improved the parents had been advised to bring the child to the hospital Family history revcaled that the parents wre healthy but that the only other sibling had cystic eosis antibiotics and expecrs PHYSICAL EXAMINATION Physical examination revealed an active child in no acu distress but with an almost consant, wet-sounding cough emperature was 102 3" F. The abdomen was protuberant. The child was in the fortieth peroenile fo bright and weight. The tonsils were boggy and odemato Coarse crackles and thonchi could be auscultated over all lung fields. A moderate amount of yellow and opaque sputum was produced with cach couphing episode. The lobe and probable peeumonitis in the same area 17g%, a white blood cell (WBC)count of 21,000-and an Spo, of90% on room, air. The patomr's sweat chloride concentration was 83 mEqL(a·d0mEqL). Adupus of cystic therapist was asked to SOAP the patient. ibrosis was made. At this time, the respiratony Based en these clisical data, how would you SOAP patient? SOAPI Or

Answer 1

Answer :

SOAP 2.

S - subjective data : means what client has says.

According to case study here the client is saying iam coudghing all the time and iam having short ness of breath, and no sputum was came.

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

According to case study patient is having cyanotic skin, clubbed fingers and toes, fatigue, and weakness, and

A- assessment

Vital signs are temperature 101.6 ⁰ f,

Pulse rate is 125 b / mt

Respiratory rate is 40 b/ mt.

Blood pressure is 160/100 mm of hg.

On auscultation ronchi over both lungs,

Alveolar hyper inflation and bilateral consolidation.

According to ABG reports, ventilator failure with mild hypoxemia.

P- planning :

* Cold application for fever.

* oxygen administration by using high flow mask.

* semi Fowlers or Fowlers position,

* administrating anti pyretics and antibiotics for infection.

* intravenous fluids administration,

* intake and out put chart maintaining,

* consultation of respiratory therapist and anesthetist to ABG corrections ,

* If needed mechanical ventilatory support.

* continueous monitoring of vital signs by connecting oxygen saturation probe, and to electronic monitor.