SOAP Note Acute Asthma Exacerbation Presentation

Hello, and welcome to today’s SOAP Note presentation. My name is Lovella Delos Santos. I am currently based in a healthcare center in Upland, CA. In this presentation, we will review the case of an 8-year-old Caucasian male brought to the clinic by his mother for the management of acute asthmatic exacerbation. The symptoms began four days ago and have been increasing in intensity.

The case highlights apparent complications of pediatric asthma. As Dharmage et al. (2019) report, pediatric asthma is a leading cause of ED visits and hospitalization in the US. Severe exacerbation is a risk factor for future occurrences and can result in preventable mortalities among the pediatric population. It is thus imperative that nurses have the prerequisite asthma-related assessment and diagnostic skills.

Presentation of the Case

Subjective Information

1. is an 8-year-old Caucasian male brought to the clinic with complaints of frequent coughs and shortness of breath. The symptoms began four days ago and have been present since. They manifest intermittently, often lasting a few minutes to hours. The patient describes the cough as dry and irritating. The cough is aggravated by cold and any physical activity. The mother notes that the cough and the shortness of breath were alleviated by inhaler medications during the initial days but has since stopped responding to the medication. The cough has since worsened, with the patient experiencing multiple episodes of coughs in a day. The patient also experiences frequent night awakenings and has been unable to sleep properly in the past two nights due to the cough and chest tightness. The symptoms are accompanied by nasal flaring and fatigue.

Past medical history reveals the patient is a known asthmatic and was hospitalized a year ago for an acute asthmatic attack. He has a negative history of any other physical and psychiatric illnesses, previous surgeries, or head injuries. His father is a social drinker and smoker, while his mother has no history of substance use. The mother is a known asthmatic.

ROS

Constitutional: The patient was fatigued and had a low-grade fever.

Eyes: The patient reported periodic tearing. He denied visual loss.

ENT: Denied hearing loss or discharge. Three days ago, the patient had nasal

congestion, sneezing, and rhinorrhoea. He had an intense, unproductive cough and sore throat.

Cardiovascular: Denied irregularities in heart rate or rhythm or chest pain.

Pulmonary: The patient reported chest tightness.

Gastrointestinal: Denied abdominal discomfort, distension, or tenderness.

Musculoskeletal: Denied muscle or joint pain, stiffness, or tenderness.

Integumentary: Denied any inconsistencies in his skin color, rashes, hives, abnormal pigmentation, or any other lesions on his skin.

Neurological: The patient reported headaches.

Endocrine: He denied heat or cold intolerance or diabetes.

Hematologic/Lymphatic: Denied lymph node swelling or splenomegaly.

Allergic/Immunologic: The patient had no known allergies.

Objective Information

Vital signs: HR 122 beats per minute, BP 130/86, Temp 99.7 F, RR 31 breaths per minute, HR 122 beats per minute | BP 130/86 | Temp 99.7 F | RR 31 breaths per minute | SpO2 92%| Height -4’2 (50 percentile)| Weight – 70 lbs( 10^th percentile |BMI- 19.7 (85^th percentile. The child is at risk of overweight).| The Sp02 was also low, providing insight into a possible airway obstruction (Pereira Filho et al., 2020).

Physical exam: General examination revealed the patient was alert and responsive but fatigued. He was unable to complete a statement in a single breath. He occasionally assumed the sitting tripod position during exams. The sitting tripod position is often suggestive of respiratory distress. The chest exam was positive for bilateral wheezing sounds. There was also notable labored breathing and use of accessory muscles for respiration. All other systems were negative.

Pertinent Recent Diagnostics: The diagnostic tests performed on the patients were spirometry and a complete blood count. The patient had a FEV1/FVC of 60%, indicating a moderate airway obstruction. CBC was performed to determine the presence of an infection. In this case, CBC findings revealed a decrease in WBC count and increased lymphocyte count. This is highly suggestive of a viral infection (Pozdnyakova et al., 2020).

Assessment

The patient had shortness of breath, wheezing, coughs, and chest tightness. He was also a known asthmatic. The likely differentials include acute asthma exacerbation, acute asthma attack, bronchiectasis, and bronchiolitis.

Acute asthma exacerbation is a condition characterized by an escalation of asthmatic symptoms (Ramsahai et al., 2019). The presence of severe and more frequent asthmatic manifestations warranted the inclusion of this differential. Furthermore, assessment findings of elevated pulse and respiratory rates, symptoms of an underlying infection, and inability to complete phrases in a single breath made this diagnosis more probable.

 Viral pneumonia is another differential in the presented case. Specific cues suggestive of viral pneumonia include lower temperature, flu symptoms, and a gradual onset. Likewise, physical examination findings of tachypnea and disproportionality between temperature elevation and the level of debility (American Lung Association, 2024). This differential was considered due to the presence of tachypnea and flu symptoms in the case presented. The patient, however, reported an acute onset of symptoms, with significant coughing, wheezing, and shortness of breath, making this diagnosis less probable

Bronchiectasis is a probable diagnosis due to shortness of breath and cough. However, the absence of pleuritic pain, productive cough, and hemoptysis makes this diagnosis less probable. Bronchiectasis is underlined by marked sputum production due to a defect in the mucociliary mechanism (Talbot et al., 2024). Bronchiolitis is also probable due to the presence of shortness of breath, wheezing, and cough. A chest x-ray is warranted to exclude bronchiolitis (Manti et al., 2023).

The final diagnosis is an acute asthma exacerbation. The chest x-ray findings revealed bronchoconstriction, ruling out bronchiolitis, as bronchiolitis is often positive for small airway edema.

Plan

Diagnostics: The diagnostics ordered for the patient included a pulse oximetry, allergy testing, and chest x-ray. The pulse oximetry helped determine the oxygen saturation level and informed the need for oxygen therapy. Allergy testing was also ordered to establish whether the patient is allergic to animal dander or pollen. Chest x-rays helped rule out other inflammatory conditions of the airway that may result in the symptoms (Pereira Filho et al., 2020).

Treatment:

• The patient was given two puffs of  Proventil HFA using a puffer and a spacer to ease the chest congestion and alleviate the shortness of breath. The dose dose was repeated every four hours while monitoring for a decrease in oxygen saturation, and assessing dyspnea and respiratory rate. GINA guidelines recommend repeat SABA administration for children with acute asthmatic exacerbation while monitoring for deterioration in the vital signs (GINA, 2024).
• The patient was also started on Pulmicort Flexhaler at 180 mcg every 12 hours. Pulmicort Flexhaler (budesonide) is effective in addressing shortness of breath and wheezing accustomed to airway inflammation. According to the GINA guidelines, a short course of inhaled corticosteroids is necessitated for all asthmatic children presenting with acute exacerbation of the disease. Inhaled corticosteroids are effective in preventing attacks (GINA, 2024).
• Proventil® HFA was refilled at 90 mcg per actuation when necessary to help address apparent subsequent asthmatic attacks. Inhaled short-acting beta-agonists such as albuterol ( Proventil® HFA) are effective in quick relief of asthmatic attacks. GINA recommends the use of two puffs of albuterol 2.5mg/2.5ml whenever a patient experiences an asthma attack for rapid opening of the airway (GINA, 2024).

Education and Follow-Up: The patient and the family were educated on the disease process, including the likely triggers for an exacerbation. They were also told of the likely manifestations of an acute asthma exacerbation and advised to seek immediate care intervention whenever they experience an exacerbation. The patient is expected to return for follow-up after one week (Pereira Filho et al., 2020).

Holistic Approach and Caring Science

The assessment process integrated a collaborative paradigm. The therapeutic plan designed for the patient was a collective effort from the team, where different team opinions were solicited and discussed. I interacted with the patient while assessing his response to the nebulized medications. As the patient was Caucasian, there was no apparent language barrier. I was, however, keen on using simple language during the interactions.

A Jean Watson caring process that interplayed in the scenario included deepening and balance. In this case, a problem-solving solution was established that purposely addressed the patient’s complaints, demonstrating the deepening of the caring process. The balance process was achieved through an elaborate patient education. The care process for the patient was holistic as it addressed both the physical and mental wellness of the patient and family. Foremost, the care process devised a plan that addressed the physical suffering of the child. The family’s mental wellness was also addressed by including them in the design of the therapeutic plan, educating them on the disease process, and fostering a healthy patient-caregiver relationship with the family.

References

Dharmage, S. C., Perret, J. L., & Custovic, A. (2019). Epidemiology of asthma in children and adults. Frontiers in Pediatrics, 7. https://doi.org/10.3389/fped.2019.00246

Manti, S., Staiano, A., Orfeo, L., Midulla, F., Marseglia, G. L., Ghizzi, C., Zampogna, S., Carnielli, V. P., Favilli, S., Ruggieri, M., Perri, D., Di Mauro, G., Gattinara, G. C., D’Avino, A., Becherucci, P., Prete, A., Zampino, G., Lanari, M., Biban, P., … Baraldi, E. (2023). Update – 2022 Italian guidelines on the management of bronchiolitis in infants. Italian Journal of Pediatrics, 49(1). https://doi.org/10.1186/s13052-022-01392-6

Pereira Filho, F. de, Sarni, R. O., & Wandalsen, N. F. (2020). Evaluation of treatment of the exacerbation of asthma and wheezing in a pediatric emergency department. Revista Da Associação Médica Brasileira, 66(9), 1270–1276. https://doi.org/10.1590/1806-9282.66.9.1270

Pozdnyakova, O., Connell, N. T., Battinelli, E. M., Connors, J. M., Fell, G., & Kim, A. S. (2020). Clinical significance of CBC and WBC morphology in the diagnosis and clinical course of COVID-19 infection. American Journal of Clinical Pathology, 155(3), 364–375. https://doi.org/10.1093/ajcp/aqaa231

Ramsahai, J. M., Hansbro, P. M., & Wark, P. A. (2019). Mechanisms and management of asthma exacerbations. American Journal of Respiratory and Critical Care Medicine, 199(4), 423–432. https://doi.org/10.1164/rccm.201810-1931ci

Talbot, T., Roe, T., & Dushianthan, A. (2024). Management of acute life-threatening asthma exacerbations in the intensive care unit. Applied Sciences, 14(2), 693. https://doi.org/10.3390/app14020693

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I SUBMITTED A SEPARATE ORDER FOR SOAP NOTE ON ASTHMA EXACERBATION AND BELOW IS ORDER FOR A SCRIPT FOR MY ORAL PRESENTATION. PLEASE FOLLOW ALL THE DIRECTIONS THEY PROVIDED. MY TOPIC IS ASTHMA EXACERBATION.

Signature Assignment Description/Directions: Develop a SOAP note and accompanying oral presentation. Choose a memorable, interesting, or challenging patient encounter during this clinical rotation that you have not previously presented to your class or submitted for a SOAP note. Do not use simple cases such as URI or UTI symptoms, ear pain, sore throat, follow-ups, or runny nose. Ask your instructor if you are in doubt whether or not your case is challenging or interesting.

Directions:

1. Submit a written SOAP note for this case, with an assessment and plan that demonstrate critical thinking skills and application of evidence based practice.
2.  Support your clinical decision making with at least two (2) peer-reviewed references other than required course textbooks.
3. After writing your SOAP note, record an oral presentation to accompany the note to describe the case to your instructor and classmates.
4. Engage your audience and explain why the case was a meaningful learning opportunity. Spend more time on the sections discussing why the case was meaningful, your critical thinking process, and your holistic approach and caring science, since the written portion will elaborate on the medical aspects of the case. Keep the oral presentation of the facts of the case brief.
5. Explain which resources you used and which portions of the history or physical led you to the chosen diagnosis and include the evidence that supported your decision making and treatment plan.
6. In the presentation, include how you incorporated a holistic approach and how you applied one of Jean Watson’s ten carative factors into your care of this patient.
   

   SOAP Note Acute Asthma Exacerbation Presentation

Include the following in your oral presentation:

• Introduction
  • Your name
  • Your clinical site/type and location
  • Brief description of the case (ID, CC, brief HPI)
• Describe why the case was meaningful, memorable, interesting, or challenging to you
• Presentation of case (brief)
  • Subjective information
    • ID, CC, HPI
    • PMH, SH, FH
    • ROS
  • Objective Information
    • Vital Signs (if all are normal, it is ok to say so)
    • Physical Exam (only describe pertinent findings, otherwise it is ok to say unremarkable)
    • Pertinent recent diagnostics (if available)
  • Assessment
    • Differentials you considered
    • Resources used to narrow the differentials
    • Your critical thinking process
    • Final diagnosis and any secondary diagnoses
  • Plan
    • Diagnostic, therapeutic, educational and follow up components
    • Application of evidence based practice
      • Why did you select the chosen therapy/referral/diagnostic approach
      • What support is there for your plan
      • What alternatives were considered
• Holistic Approach and Caring Science
  • Provide examples of how you collaborated or could have collaborated with the patient, family, or other members of the care team to achieve better healthcare outcomes. Include cultural considerations.
  • Which of Jean Watson’s Caring Processes were considered with this patient?
  • In what ways was your care of this patient representative of a holistic approach?