SOAP Note Anticogaulant Therapy PDF

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SOAP Noted Anticoagulant Therapy...

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Unit 5 Discussion 2 - Anticoagulant Therapy Scenario: A 77-year-old white male comes into your office complaining of feeling dizzy, short of breath, easily fatigued, and having a sensation of his heart 'skipping beats.'      

He reports he has had these same symptoms numerous times over the last year or so, but they only lasted for about a day. He thought since he has been experiencing them now for about three days, he should come in and get checked out. He was diagnosed with type 2 diabetes twenty years ago and hypertension fifteen years ago. Current medications include Lisinopril 20 mg daily and Metformin 1000 mg daily. BP 172/100, P 123 irregularly irregular, R 20 Skin is warm, pale with a slight gray cast; lungs are clear to auscultation; heart irregular rhythm

Please develop a discussion that responds to each of the following prompts. Where appropriate your discussion needs to be supported by scholarly resources. Be sure to include in-text citations in the context of the discussion and provide a full reference citation at the end of the discussion. Initial post Utilize the information provided in the scenario to create your discussion post. Construct your response as an abbreviated SOAP note (Subjective Objective Assessment Plan). Structure your 'P' in the following format: [NOTE: if any of the 3 categories is not applicable to your plan please use the 'heading' and after the ':' input N/A] Therapeutics: pharmacologic interventions, if any – new or revisions to existing; include considerations for OTC agents (pharmacologic and non-pharmacologic/alternative); [optional - any other therapies in lieu of pharmacologic intervention] Educational: health information clients need to address their presenting problem(s); health information in support of any of the 'therapeutics' identified above; information about followup care where appropriate; provision of anticipatory guidance and counseling during the context of the office visit Consultation/Collaboration: if appropriate - collaborative 'Advanced Care Planning' with the patient/patient's care giver; if appropriate -placing the patient in a Transitional Care Model for appropriate pharmacologic and non-pharmacologic care; if appropriate – consult with or referral to another provider while the patient is still in the office; Identification of any future referral you would consider making Support the interventions outlined in your 'P' with scholarly resources.

Scenario (S): A 77-year old white male is here for a visit with a complaint of feeling dizzy, shortness of breath, easily fatigued, and having a sensation of his heat "skipping beats." He states he has had these symptoms numerous times over the last year or so, but they only last for about a day. This episode has lasted for three days, so he wants to get checked out. He has a history of type II diabetes for 20 years and hypertension 15 years ago. He is currently taking Lisinopril 20mg a day and Metformin 100mg daily. Objective (O): BP 172/100. P 123 irregular, RR 20. The skin is warm and pale with a slight grey cast. Lungs are clear bilaterally upon auscultation. The heart is beating in an irregular rhythm. Assessment (A): After my assessment, the patient is experiencing a cardiac arrhythmia. Irregular heart rates are irregular cardiac rhythms including, rapid heart rate and low heart rate. An arrhythmia may be with or without symptoms, causing a feeling of one's heart beating too fast, too slow, or skipping a beat, and can cause a deficit in consciousness, cardiac collapse, and mortality. (Arcangelo, Peterson, Wilbur, & Reinhold, 2017). Irregular heart rates can be caused by mechanical or transference regularity variations in the heart that can decrease the hearts' performance and hearts' productivity. (Arcangelo et al., 2017). Plan (P): A completed cardiac workup with labs and investigative studies are necessary to diagnose a cardiac arrhythmia. (Arcangelo et al., 2017). I would order a 12-lead electrocardiogram to determine if the patient has any cardiac tissue damage, assess the PQRST intervals, diagnose and early atrial or ventricular shortenings, heart blocks, and absent cardiac waves. (Arcangelo et al., 2017). A CBC, BMP, TSH levels, and a digoxin measurement are needed to detect any fundamental triggers of the irregular heart rate, heart enzymes, a stress test, and possible cath lab examination. (Arcangelo et al., 2017). Before beginning anticoagulant therapy, "baseline laboratory values including PT, INR, aPTT, urinalysis, CBC (with platelet count and a liver profile are recommended." (Arcangelo et al,. 2017, p. 870). I would recommend a rectal exam or occult stool sample to "rule out any major bleeding from the central nervous system or gastrointestinal tract." (Arcangelo et al,. 2017, p. 870). A review of all the patients' past medical history, previous surgeries, and a thorough review of all medication the patient takes, prescription, over the counter or herbal supplements, to review the risk of bleeding. (Arcangelo et al., 2017). Therapeutics: The need for the patient to take an anticoagulant must be documented to help clarify the extent of treatment, and if the medication is warfarin, to determine the target INR, which will outline the strength of the medicine. (Arcangelo et al., 2017). If the patient begins taking low molecular weight heparin or a direct oral anticoagulant, the patients' body weight, "serum creatinine, estimation of renal function creatinine clearance should be calculated." (Arcangelo et al,. 2017, p. 870 - 871). If the patient is prescribed unfractionated heparin, it is vital to monitor the patients body weight. (Arcangelo et al., 2017). "Anticoagulants include the injectable agents' unfractionated heparin (UFH) and lowmolecular-weight heparins (LMWHs) (e.g., enoxaparin), oral vitamin K antagonist (VKA) warfarin, and the direct-acting oral anticoagulants (DOACs) dabigatran etexilate (a direct thrombin inhibitors), and oral factor Xa inhibitors (rivaroxaban, apixaban, and edoxaban)." (Arcangelo, 20161108, p. 871). If warfarin (Coumadin) is used, it has many drug and food

interactions, a narrow therapy range, and needs to have the lab of the INR and liver enzymes checked every month to month and a half. (Arcangelo et al., 2017). Education: The patient will need to be educated not to take herbal remedies that contain bilberry, garlic, ginger, fish oil, feverfew, ginseng, and green tea because of the inclusion of vitamin K. (Arcangelo et al., 2017). Warfarin is to be taken orally one time a day. (Arcangelo et al., 2017). Vitamin k is the antidote to warfarin, so many foods cannot be consumed, such as "spinach, turnips, collard, mustard greens, broccoli, Brussel sprouts, and cabbage, herbal and green teas." (Arcangelo et al., 2017, p. 878). Vitamin K is located soy products and olive oils, so the patient will need to read all labels carefully. (Arcangelo et al., 2017). Due to his current cardiac issues, I would also recommend avoiding stressors, eating a cardiac diet, avoidance of caffeine, regular exercise, and continue with labs and follow-up appointments. (Arcangelo et al., 2017). The patient needs education about the risk of bleeding from the mouth, nose, urine, excrement, nose bleeds, bruising, blood, gastrointestinal bleeds, and vomiting blood and to see emergency room treatment for bleeding that is not stopped. (Arcangelo et al., 2017). If the patient is to fall, there is a risk of intracranial bleeding and will need to be evaluated at the emergency room as soon as possible. (Arcangelo et al., 2017). Consultation: I would like to refer the patient to see a cardiologist for a complete workup and to make sure the patient does not have any damage that occurred from the irregular heart rhythm. Reference: Arcangelo, V. P., Peterson, A. M., Wilbur, V., Reinhold, J. A. (20161108). Pharmacotherapeutics for Advanced Practice, 4th Edition [VitalSource Bookshelf version]. Retrieved from vbk://9781496374066...