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It is the mandate of every practicing nurse to ensure that they record the daily experiences with the patients. The data helps to make a follow-up care to the patient in the subsequent visits to the hospital. Among the different records kept are the SOAP Notes that have detailed information about the process of diagnosing a disease condition. Women suffer from different health problems Zack Steffen USA Jersey , hence important to keep track of them all. The SOAP note provided regard a patient I examined in my practicum experience having Urinary Incontinence.
Subjective
A 42-year-old Caucasian female complains of urine leakage that occurs on a daily basis. The condition has been evident for an approximate of two years and has progressed forcing her to use more than two pads per day. Her main concern is due to the condition that distracts her daily chores. At some instances, she has involuntary loss of urine upon forceful squeezing, coughing, and jumping. She gave birth normally to all her children and without any complications. She takes a healthy diet, but her medical history reveals that she had high blood pressure and diabetes. Her current medication is hydrochlorothiazide. According to her personal history, the lady is not active Walker Zimmerman USA Jersey , takes alcohol, does not smoke, and performs no exercise. Her mother passed on due to diabetes.
Objective
The Vital signs indicated that her temperature was 36.9 掳 C, and heart rate of 87 with Blood pressure 13090. She was alert, healthy, and in good posture. Her skin had a uniform color and did not have a foul smell. A pelvic examination showed that she did not have any inflammation Timothy Weah USA Jersey , infection or paleness. However, there was the presence of urine leakage during her daily chores. A pyridinium test reveals that she has a urine loss.
Assessment
The differential diagnosis for the patient is stress urinary incontinence, High blood pressure levels, Urinary obstruction, and acute urinary tract infection. The primary diagnosis for the patient is Stress Urinary Incontinence. The condition involves leakage of the bladder during physical activity or excretion. It may occur during coughing, or lifting something heavy. The main cause is weakening of the muscles that control the ability to hold. The pelvic floor muscles and the sphincter muscle are the main controls of the flow of urine. The weakening of the muscles may be due to injury of the urethra region Tim Ream USA Jersey , childbirth, and other complex cases (Schuiling & Likis, 2013). The lady had a previous diagnosis of controlled hypertension and diabetes, and the recommended medication was hydrochlorothiazide.

The pharmacological therapy involves the use of 伪-Adrenergic Agonists that helps in muscle contraction upon stimulation. Also prescribed was Imipramine, which is antidepressant to help in storage of urine; and Duloxetine that enhances urethral activity by suppressing the bladder activity. A hormone therapy of sex steroid was appropriate to influence continence by increasing urethral outlet resistance.
For the follow-up care, I advised the lady to return to the hospital after three months to check the progress of the prognosis. I also required the patient to return for response medication assessment after two weeks. The patient did not require a further assessment, hence was not referred to a gynecologist or Urologist. I encouraged the patient to take a healthy diet comprising of low fat Sacha Kljestan USA Jersey , low salt, low cholesterol, high fiber, high carbohydrates, and plenty of water for the management of diabetes and hypertension (Tharpe, Farley & Jordan Paul Arriola USA Jersey , 2013).
Reflection Notes
The use of Soap notes helps to enhance the mode of service delivery by providing an accessible record of tracking the overall progress if the patient. The soap note helped to increase my level of understanding about women health and also the interventions, promotions, and preventions to address the disease conditions. For the case presented, I think that it would be necessary to have a record of the levels of urine output and also recommend the patient to record the frequency of urine release. The data helps in the diagnosis as well as for following-up care. The use of soap notes to clinical practice is a good way of ensuring that patients develop trust with the provider since they show a track of all the disease conditions treated previously. Practitioner nurses have an obligation of ensuring that the patients get quality services and have focused care through proper record keeping.

References

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