Question

my teacher wants this soap note in PES format, what does that mean?

ASSESSMENT:  

At risk for impaired gas exchange, as evidence by crackles in the posterior lung fields and pain with deep breathing.

1. Ineffective Airway clearance related to expectorate as evidence by adventitious breath sounds
2. Risk for aspiration as evidence by ineffective cough. Risk for is not PES format
3. Readiness to learn about smoking sessation

Pt has a temperature. I would imagine that should be more of a priority at this time rather then smoking cessation.

PLAN:  

1. Manage Airway

1. Nurse will monitor respiratory patterns, including rate, depth, and effort. “A normal respiratory rate for an adult without dyspnea is 10 to 20 (Jarvis, 2012). With secretions in the airway, the respiratory rate will increase.”
2. Help the client deep breathe and perform controlled coughing. Have the client inhale deeply, hold breath for several seconds, and cough two or three times with mouth open while tightening the upper abdominal muscles. “Controlled coughing uses the diaphragmatic muscles, making the cough more forceful and effective (Gosselink et al, 2008).”
3. Encourage fluid intake of up to 2500 mL/day within cardiac or renal reserve. “Fluids help minimize mucosal drying and maximize ciliary action to move secretions.”

2. Aspiration precautions
   1. Auscultate lung sounds frequently and before and after feedings; note any new onset of crackles or wheezing. Auscultation of lung sounds was shown to be specific in identifying clients at risk for aspirating (Shaw et al, 2004).
   2. If the client shows symptoms of nausea and vomiting, position on side. “The side-lying position can help the client expel the vomitus, and decrease possible aspiration”.
   3. Keep the head of bed elevated at 30 to 45 degrees, preferably sitting up in a chair at 90 degrees when feeding. Keep head elevated for an hour afterward. Maintaining a sitting position with and after meals can help decrease aspiration pneumonia (Guy & Smith, 2009).
3. Smoking cessation
   1. Teach the client to identify and avoid specific factors that exacerbate ineffective breathing patterns, such as exposure to other sources of air pollution, especially smoking.
   2. If the client smokes, aggressively counsel the client to stop smoking and refer to the physician for medications to support nicotine withdrawal and a smoking withdrawal program. “A Cochrane review found that use of the medication varenicline (Chantix) increased the rate of smoking withdrawal two to three times more than smoking withdrawal without use of medications (Cahill, Stead, & Lancaster, 2008). “
   3. Use motivational interviewing to help the client identify and change unhealthy behaviors. In these studies of smokers and substance abusers, MI (motivational interviewing) was helpful in promoting smoking cessation and reduction of substance use (Laiet al, 2010; Smedslund et al, 2011).

Answer 1

PSE FORMAT:

PSE format published by Dr. Marjory Gordon, a founder and former President of NAND API.

Converting SOAP format into Problem, Etiology, Symptom format by analyzing the patient sheet.

Example refer below snap:

Components of a NANDA-I Nursing Diagnosis Acute Pain related to tissue ischemia as evidenced by statement of "I feel severe pain on my chest." (Problem (E)tiology (s)igns and Symptoms

ABOVE FORMAT:

PROBLEM:

• Impaired gaseous exchange
• Ineffective airway clearance
• Risk for aspiration
• Temperature

ETIOLOGY:

• Crackle lung field
• Wheeze
• Ineffective Cough
• Pyrexia

SYMPTOMS/CHARACTERISTIC:

• Pain with deep breathing, Abnormal atrial blood gas and pH.
• Abnormal breathing.
• Difficulty breathing, Altered chest excursion, changes in respiratory rate and depth.
• Aspiration and dryness of mucosal layer, Pain in thoart.
• Abnormal body temperature above normal, Dehydration, Fatigue.

​​​​