Nursing Assignment Help and Services Samples - Soap Note for Croup

Samples for Nursing Assignment Help and Essays - Soap Note for Croup

Subjective data

Chief Complaint (CC): Barking cough, hoarse cries, and crowing noise during breathing

History of present illness (HPI): Antony James (AJ), a 13-month-old African American boy, is carried by his mother to a clinic where I was working two weeks ago for a medical check-up. AJ’s mother notes that for the last two days, her son has been coughing while producing a barking sound. When he is crying and attempting to talk, there is a hoarse voice. The mother also notes that the son has been producing crowing voice when breathing. The situation worsened last night when AJ had difficulties in breathing especially when he is lying down. The mother notes that she has had to sit her son upright for ease in breathing. The cough has been stressing AJ mother who must be awake to observe her child. The mother is also keen to note that there is a slightly higher fever.

Current medication: AJ mother notes that she has been using no medicine recently to treat the condition thus her reason to seek medical assistance.

Allergies: Currently, the mother notes no allergies.

Past Medical History (PMH): AJ mother notes that there is no previous serious medical condition on her son beside the common cold and diarrhea which was as a result of bacterial infection.

Past Surgical History (PSH): The mother notes that there is no past surgical condition.

Personal/Social history: AJ is a healthy child who has been brought up by the mother in the best way possible through nutritional balance and intake of lots of fluids. Further, AJ is still breastfeeding although the mother has been reducing the frequency.

 : According to AJ’s mother, and as noted in the growth chart, AJ is current on all his immunizations including RV1, Tetanus, Diphtheria, PCV13, and HepB.

Family History: AJ parents are all working and are successful in their careers. Both parents are healthy as well as their first born daughter who is five years old. Socially, the family loves fun although it’s occasional.

Review of systems

General: According to AJ’s mother, her son has constantly been coughing while producing barking sounds. Further, he has challenges in breathing and especially when he is sleeping. The mother has been forced to sit him up to aid in easy breathing. The difficulty in breathing is reflected by the crowing noise and fast inhalation. When crying and groaning, there is a hoarse voice.

Skin: According to the mother, there are no skin abnormalities, scars nor rashes.

HEENT: According to the mother, AJ has no vision or hearing challenges. However, there are challenges in breathing although no nose bleeding. The child is teething although there are no challenges affiliated to this aspect. Notable challenges in breathing and voice include hoarse voice, wheezing sound when breathing and harsh coughing

Neck: Mother denies any challenges

Respiratory: Breathing fast, wheezing, barking sound in coughing.

Cardiovascular: Mother denies

Gastrointestinal: Mother denies

Peripheral Vascular: Mother denies

Urinary: Mother denies

Genital: Mother denies

Musculoskeletal: Mother denies

Psychiatric: Mother denies

Neurological: Mother denies

Hematologic: Mother denies

Endocrine: Mother denies

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OBJECTIVE DATA

Vital Signs: Height 24 inches, Weight 22 lbs, Blood pressure 104/74, Temperature 97K, BMI 20.2, HR 124, RR 24, O2 98%

General: Antony James (AJ), a 13-month old male child, appears sickly as reflected on his face. There are no signs of illness until a close interaction with the child who is breathing heavily and through the mouth and nose. Important factor to note is that he is attentive to the surrounding. He is healthy, and there are no noticeable hearing or sight challenges. There are no movement challenges.

Skin: His skin is intact with no rashes. No jaundice and the skin is even in color.

HEENT: Head is norcephalic, and there is no indentation. Based on his age, the head is appropriate and no scaling, lesions or dryness. He has smooth hair. Pupils are equal and responsive to light. No presence of injected conjunctiva. Further, no lesions or oedema in his eyes. He is teething though no bad odor.

Neck: Neck is supple with no LAD

Throat: Presence of few sores and exudate.

Lungs:  Lungs indicate positive expiratory wheezes and slight blockage.

Heart/Vascular/Peripheral: Regular rhythm and heart rate. Few bruit murmurs and rubs.

Abdomen: No lesions not masses. Active and normal bowel sounds. In all four quadrants, it is not tender to palpation.

Neurologic: No localization and is responsive to the environment

Musculoskeletal: Positive ROM

ASSESSMENT

Main diagnosis

In regards to the identified symptoms which include a barking cough, breathing difficulties, croaky voice and a harsh grating sound during breathing, AJ’s primary diagnosis is Croup. Further by virtue that the mother notes that the symptoms worsen at night and the difficulty in breathing is averted by siting the son upright, they are more evidence of Croup (Petrocheilou et al., 2014). In addition, there are few sores in the throat and a slightly high temperature. The condition is caused by a virus which is usually present during this time of the year. The barking voice and wheezing sounds are as a result of the infection causing the swelling of the larynx and the windpipe becoming blocked which affect the lungs tubes, bronchi (Branche & Falsey, 2016). The virus is transmitted through close contact with infected people as well as contaminated surfaces and objects. The management of the condition is through pharmaceutical and therapeutic approaches.

Differential diagnosis

Laryngitis

The condition is described by the inflammation of the voice box with symptoms being hoarseness, challenges in speaking, sore throats, fever and irritating cough. Within the first three days, the cough is noted to worsen. There are cases where the larynx can swell resulting in breathing challenges. Although the condition is common in adults, children can also get the infection. Other conditions that may be affiliated with this disease are a headache, running nose and swollen glands (Weinberger & Fischer, 2014). Notably, AJ's symptoms are similar to those of Laryngitis thus the reason to conclude it as a possible condition.

Epiglottitis

This is a condition characterized by the swelling and blockage of the air flowing to the lungs. There are several causes of the condition which include injury to the throat and infections. In children, the condition was in the past affiliated with the bacterium that causes pneumonia. Although the condition can occur to anyone, the symptoms in children include a sore throat, fever, high pitch sound when breathing, and restlessness (Weinberger & Fischer, 2014). Similarly to Laryngitis, the symptoms are similar to those of AJ thus the need to consider Epiglottitis as a possible condition.

Retropharyngeal Abscess

Retropharyngeal Abscess is a condition that it caused by bacterial infection. It is described as the accumulation of pus in the lymph nodes and throat. The results of this pus collection include pain during swallowing, stiff neck, and noise when breathing. However, there is little relation between AJ symptoms and those of this condition although the difficulty in breathing suffices considering it as a differential diagnosis. Unlike the above three conditions, treatment of Retropharyngeal Abscess is done surgically and using medication (Weiberger & Fischer, 2014). Some of the medications include antibiotics and pain relievers.

Plan

Culture: Croup is usually managed at home unless there are chronic symptoms such as a severe headache.

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Treatment

Based on the symptoms and diagnosis, it is apparent that AJ is suffering from Croup disease which probably he got from contact with and infected child or contaminated object. As a treatment approach, I recommended both medical and therapeutic approach. I recommend managing the condition at home as the symptoms are not serious (Burns et al., 2013). Notably, the medication is to avert the fever and possible pain which may emanate from swallowing. In this regard, paracetamol would suffice to ease the pain and reduce the fever. Also, I prescribed oral corticosteroid which would reduce the swelling. Considering the non-pharmaceutical approach, this would involve giving AJ lots of fluids for hydration (Hagan, Shaw & Duncan, 2008). To mitigate the difficulty in breathing and especially at night, I recommended AJ mother sleeping next to him and being observant to sit him up whenever there is a challenge in breathing. Other measures included maintaining a clean environment (Petrocheilou et al., 2014). It is, however, important to warn against the side effects of the medication which include vomiting and restlessness. Further recommendation was returning to the clinic if the conditions got worse.

Reflection

The entire process of diagnosing a toddler and developing a successful plan was satisfactory in giving me the required experience in the medical field. It has always been my passion to understand children related conditions and develop beneficial interventions. Croup is a condition which requires management from home unless there are severe symptoms. This implies that there are no special recommendations I would have made on AJ’s condition beside the paracetamol, oral corticosteroid and intake of fluids. Developing a successful intervention for the patient gave me the great feeling of achieving my main goal of becoming a profound heath care provider.

References

Branche, A. R., & Falsey, A. R. (2016, August). Parainfluenza Virus Infection. In Seminars in Respiratory and Critical Care Medicine (Vol. 37, No. 04, pp. 538-554). Thieme Medical Publishers.

Burns, C. E., Dunn, A. M., Brady, M. A., Starr, N. B., & Blosser, C. G. (Eds.). (2013). Pediatric primary care(5th ed.). Philadelphia, PA: Elsevier.

Hagan, J. F., Jr., Shaw, J. S., Duncan, P. M. (Eds.). (2008). Bright futures: Guidelines for health supervision of infants, children, and adolescents (3rd ed.). Elk Grove Village, IL: American Academy of Pediatrics.

Petrocheilou, A., Tanou, K., Kalampouka, E., Malakasioti, G., Giannios, C., & Kaditis, A. G. (2014). Viral croup: Diagnosis and a treatment algorithm. Pediatric pulmonology, 49(5), 421-429.

Weinberger, M., & Fischer, A. (2014, March). Differential diagnosis of chronic cough in children. In Allergy and Asthma Proceedings (Vol. 35, No. 2, pp. 95-103). OceanSide Publications, Inc.

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