Question

1. Summerize each of the two different charts below, how they will be used in your chosen career, proposed improvements and better ways this information could be conveyed.
2. SOAP Charting
   1. include the list below and put the items in a SOAP format. You will want to research to find a form of your choice. You may add words to make sentences out of some of these items. When you get done, you should be able to view the notes and have a picture of this patient and know the next steps. Make sure that you have the needed information from your research of SOAP notes.
      1. John Smith, DOB 08-10-1951 came into the clinic to see Dr. Jerry Jones. Below are notes taken during Mr. Smith’s visit.
      2. Blood Pressure: 165/85
      3. Patient complains of left arm pain.
      4. Complains of leg weakness and increases with going up steps
      5. Diagnosis: Hypertension, bilateral edema legs, and ankles, Heart Disease, Diabetes
      6. Elevate legs for 1 hour 4 times a day
      7. Height: 182 cm
      8. Inflammation on both lower legs
      9. Pain is aching
      10. Pain is better when I elevate my legs
      11. Pain is worse at night
      12. Peripheral edema, both ankles
      13. Prescribe Hydrochlorothiazide, 25 mg tablet, 1 per day in the am.
      14. Pulse Oximetry: 97%
      15. Pulse: 60 bpm
      16. Rate pain 5 out of 10
      17. Respiration: 16 bpm
      18. Return for follow-up in two weeks
      19. Temperature: 98.5
      20. Wear support stockings till next appointment
      21. Weight: 165 kg
      22. X-rays show no fractures
3. PIE Charting Assignment
   1. Review the bottom of page 160 of your text for patient charting using the PIE method. Using your creative mind, create a problem, provide interventions, and identify the results (evaluation). Your problem should include a paragraph, interventions and evaluation is a paragraph

Answer 1

ANSWER.

68 year old patient named Sohel ryan has been admitted to hospital for vision problems and severe headaches.

Sohel ryan also said that he have:-

* Blood in urine.

* Dizziness.

* Chest pain.

* Difficulty breathing.

Doctor assumed it as hypertension and said nurse to check bloood pressure,it is:-

180/120.

Doctor also ordered:-

* Cholesterol test.

* Blood test.

* Electrocardiogram.

* Urinalysis.

After the diagnosis,it is proved that the condition is hypertension and doctor ordered medications:-

* Metalazone

* Amlodipine.

Nursing interventions:-

* Take a low sodium diet.

* Decrease the weight.

* Education about medications.

* Regular exercises are required.

* Maintain the personal hygiene.