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SOAP Note #2

Rachel Neale

Department of Nursing, Pennsylvania College of Health Sciences

NUR 631: Nurse Educator in Clinical Practice

Dr. Rita Wise

July 23, 2023

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Patient initials: H.K.

Date: 7/5/23

Subjective

CC: “I am here for my 32 week OB appointment”

Subjective: Pt presents to office for routine 32week obstetric appointment. Pt reports monitoring

glucose levels four times daily, 1 fasting blood glucose (FBG) and then 3 2hour postprandial

levels. No specific complaints.

Presenting Problem (OLDCARTS): Pt diagnosed last appointment with gestational diabetes

(GDM) and has brought in her log of blood glucose readings. Almost all of her FBG readings are

elevated in the low 100s (goal is 95 or less), though almost all of her postprandial levels are

normal, which keeps her total number of abnormal levels less than 30%, meeting her goal. Pt

reports being on a keto diet and taking the GDM diagnosis very seriously. She also typically has

cheese and crackers for her nighttime snack and reports going for a walk almost every evening in

an attempt to improve her FBG levels. Pt reports being unable to find a nighttime snack that gets

her FBG in normal range, despite making various changes.

Allergies: NKA

PMH:

G2P1001

-gestational diabetes this pregnancy

-Attention Deficit Disorder

-dysmenorrhea

-excematous dermatitis

Surgical History:
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-cesarean delivery 2018

Current Medications:

-prenatal vitamin-1 tablet daily

Family history:

Father: (alive) hyperlipidemia

Mother: (alive) thyroid disease, benign brain tumor

sister: (alive) no known diseases/conditions

brother: (alive) allergy (undefined allergen)

maternal grandmother: (alive) thyroid disease

maternal grandfather: (deceased) stroke

paternal grandmother: (deceased) Alzheimer’s disease

paternal grandfather: (deceased) pulmonary embolism

ROS:

General: pt reports overall difficulty managing fasting blood glucose levels

Integumentary: denies any skin lesions, concerns.

Psychiatric: reports occasional difficulty sleeping, but denies depressed mood or anxiety.

Neuro: denies any headaches, difficulty swallowing, memory issues. denies history of head

trauma or stroke

HEENT: denies any vision changes (spots or blurred vision), denies any nasal congestion, sore

throat, goiter.

Respiratory: denies any SOB, cough.

Cardiac/Circulatory: denies chest pain, heart palpitations. Reports increase in fatigue with here

evening walks, unable to walk as much as she had been.

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Peripheral Nervous System: Reports mild dependent edema that is worst after a long day and

resolves with positioning feet up and is absent first thing in the morning. Denies any tingling or

numbness.

GI: denies any nausea/vomiting, denies regular diarrhea/constipation. Reports well-rounded diet

(see Endocrine)

GU: reports positive fetal movement, denies any vaginal bleeding, loss of fluid.

Musculoskeletal: denies any significant muscle pain/soreness, denies a history of falling.

Endocrine: Reports trying to adhere to keto diet and typically eats cheese and crackers for

bedtime snack along with taking a walk (approximately 30 minutes in duration). Pt states her

fasting blood glucose levels remain high despite making change to her diet. Denies polyuria,

polyphagia, polydipsia.

Objective

Focused Assessment:

Vital Signs: 140/90 (recheck 140/92), ht 5’2”, wt 170lb, BMI 31.16

BP at prior two appointments were also initially elevated in 140s/90s but rechecks were

normal

Pertinent labs:

6/13 protein/creatinine ratio: 0.45

hemoglobin 10.8

platelets 282

glucose 1hr: 209

2hr: 160

3hr: 117
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(all other values WDL)

6/15 24hr urine collection protein/creatinine ratio: 186

General: pt well dressed, appropriate in speech, noticeable gravid uterus.

Skin: dry and intact

Neuro: AxO x4

HEENT: pt not wearing glasses, speaking without any difficulty. Trachea not deviated; no goiter

noticeable.

Respiratory: breathing unlabored, no signs of respiratory distress, no use of accessory muscles

Cardiac/Circulatory: blood pressure elevated, 140/92 with manual cuff. Upper/lower extremities

are pink in color, cap refill normal, mild dependent edema noted, +1.

GI: gravid uterus, otherwise nontender abdomen

GU: fetal heart rate 150 bpm, uterus measuring 32cm, fetus vertex per Leopold’s Maneuvers

Musculoskeletal: full ROM, independently able to ambulate and move around exam room

Endocrine: according to patient’s glucose log checking FBG all running in low 100s, but

majority of postprandial checks are within normal limits.

Assessment

Diagnosis: Gestational Hypertension, gestational diabetes-diet controlled

With having had two blood pressures that are at least 15 minutes apart and greater than

140/90, and because patient is greater than 20 weeks gestation, pt is diagnosed with gestational

hypertension (GHTN) (Stanford Medicine, n.d.). According to UpToDate (2023a), GHTN must

be clarified from pre-eclampsia which would be diagnosed with elevated pressures and

proteinuria. HK did have an elevated protein/creatinine ratio but her 24hr urine collection

demonstrated a normal amount of proteinuria. With patient denying any signs of pre-eclampsia,
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gestational hypertension is the most likely diagnosis at this time. Further labwork will be needed

to determine absence of pre-eclampsia. Pt also still maintains the diagnosis of gestational

diabetes, but does not currently need medication to control her levels, so she is diet controlled.

Educational Needs:

Pt will need education regarding how to manage her blood pressure at this point, as she

needs to be on the lookout for what is a severe range blood pressure and requires a hospital visit

versus what is a normal elevated blood pressure for her. Pt will also need education on when to

best take her blood pressure at home, and how to take it correctly (see Patient Education below

for specifics).

Pt was very tearful at this diagnosis of her gestational hypertension, stating “my last

pregnancy was so easy”. Pt needs reassurance that though some are at higher risk for developing

GDM and GHTN , this was not her fault and not something she could have caused. HK needs

encouragement that her dedication to improving her glucose levels is commendable and will

benefit her baby if she perseveres. Finally, HK can be reassured that hypertensive disorders in

pregnancy are fairly common affecting approximately 5-8% of pregnancies, and that she is not

alone in receiving this diagnosis (da Silva Jacob et al., 2022).

Plan

Because GHTN can be a risk for pre-eclampsia, stroke, stillbirth, and maternal death, this

diagnosis launched several orders (Stanford Medicine, n.d.). The biggest change is that the

patient is now ordered labetalol 100mg PO BID to manage her blood pressures and a daily 81mg

aspirin PO to also be started to reduce risk of clotting disorders such as Deep Vein Thrombosis or

stroke (deBoer et al., 2017). To go along with that a blood pressure cuff was also ordered so that

she can check her blood pressure once or twice a day at home, and that hopefully insurance
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would cover the cost of the cuff. Although at 32 weeks most patients come in for prenatal

appointments every 2 weeks until 36weeks, this patient will now come into the office every week

until delivery for a routine prenatal appointment as well as weekly Non-stress tests (NSTs).

Finally, a panel of labwork is ordered to be drawn and collected today in the office to rule out

pre-eclampsia/HELLP syndrome, including CBC/CMP and urine protein/creatinine ratio.

Patient Education

1) GHTN vs. pre-eclampsia: Because patients that have GHTN are at an elevated risk to develop

superimposed pre-eclampsia HK needs to be on the lookout for signs of pre-eclampsia, including

headache, blurry vision or floaters, shortness of breath, right upper quadrant pain,

nausea/vomiting, and swelling of face/hands/legs (Stanford Medicine, n.d.). HK is instructed to

call the office for any of those symptoms, and the on-call midwife will call her back. This

information is best presented as a patient education attachment on her discharge paperwork so

that she can reference it in the future.

2) How to take an accurate blood pressure cuff: HK must be taught how and when to take a

proper blood pressure at home so that she does not get an artificially elevated pressure and

needlessly present to the hospital for further evaluation. This involves sitting down for a few

minutes and be at least 30 minutes out from exercise, feet flat on the floor and her arm at the

level of her heart (UpToDate, 2023b). HK is also educated that she needs to call for any blood

pressure greater than 160/110, which would warrant further evaluation (UpToDate, 2023a).

Though there was not time during this lengthy appointment to teach her how to grab an accurate

BP, HK should be instructed to bring her BP cuff into the office and a healthcare provider can

ensure that she is educated correctly on taking her blood pressure at home by watching her take it

in the position she would at home. This could also be compared with the BP taken at the office to
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see how similar the readings are and to give her confidence in her readings that she takes at

home.

3) NST Education: Due to her GHTN the pt will now need weekly NSTs. To make the education

accessible to HK, it is presented as a way of checking the baby’s general well-being by looking

at the heart rate over a twenty minute time period. NSTs check to see the fetus’s oxygenation

status without stimulating contractions artificially. A large amount of the education with regards

to this test will come verbally during the NST, and the nurse performing it can visually show the

patient what is being recorded, what is an acceleration and variability in the heart, and that

demonstrates fetal well-being.

4) Improving glucose level: It is recommended that HK continue what she is currently doing

with her diet to manage her glucose levels, and to maybe switch out the crackers in the evening

with a high protein or high seed content cracker, which may improve the FBG the following

morning. HK encouraged to continue her evening walks. Giving a handout to HK with a list of

high protein, low carb foods, or a list of recommended nighttime snacks would be helpful for her

so that she can continue to manage her GDM appropriately.

5) pregnancy precautions: As is habit for providers during any prenatal appointment, HK will

hear verbally to call for any signs of the following: vaginal bleeding, loss of fluid (i.e. her water

breaking), decreased fetal movement, pre-term labor, or pre-eclampsia (UpToDate, 2023a). This

information is given verbally but can also be given on the discharge summary paperwork that is

typically sent to their myLGHealth account to be accessed at any time by the patient.
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References

Da Silva Jacob, L.M., Mafetoni, R.R., Baena de Moraes Lopes, M.H., Kakuda Shimo, A.K.

(2022). Knowledge, attitude and practice about hypertensive gestational syndrome among

pregnant women: A randomized clinical trial. Texto Contexto Enfermagem, 31: 1-13. doi:

10.1590/19080-265X-TCE-2021-0018

DeBoer, I.H., Bangalor, S., Benetos, A., Davis, A.M., Michos, E.D. Muntner, P., Rossing, P.,

Zoungas, S., Bakris, G. (2017). Diabetes and hypertension: a position statement by the

American Diabetes Association. Diabetes Care 40(9). Https:doi.org/10.2337/dci17-0026

Stanford Medicine (n.d.). Gestational hypertension. Stanford Health Care.

https://stanfordhealthcare.org/medical-conditions/womens-health/gestational-

hypertension.html#:~:text=Gestational%20hypertension%20is%20diagnosed

%20when,increased%20protein%20in%20her%20urine.

UpToDate (2023a). Gestational hypertension. UpToDate. Retrieved 7/23/23 from

https://www.uptodate.com/contents/gestational-hypertension?search=gestational

%20hypertension&source=search_result&selectedTitle=1~99&usage_type=default&disp

lay_rank=1

UpToDate (2023b). Out of office blood pressure measurement: Ambulatory and self-measured

blood pressure monitoring. UpToDate. Retrieved 7/23/23 from

https://www.uptodate.com/contents/out-of-office-blood-pressure-measurement-

ambulatory-and-self-measured-blood-pressure-monitoring?search=blood%20pressure

%20monitoring&source=search_result&selectedTitle=1~150&usage_type=default&displ

ay_rank=1#H2145075960