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The plan will also include goals of therapy and patient-specific drug and disease-state monitoring parameters. This should address each item of the differential diagnosis. For patients who have multiple health problems that are addressed in the SOAP note, a plan is developed for each problem and is numbered accordingly based on severity and ...
There is growing evidence that psychological stress is a trigger. It can modulate the immune system, causing an increased inflammatory response to allergens and pollutants. [23] Cold weather can make it harder for patients to breathe. [24] Whether high altitude helps or worsens asthma is debatable and may vary from person to person. [25]
[9] [10] Symptoms include episodes of wheezing, coughing, chest tightness, and shortness of breath. [3] These may occur a few times a day or a few times per week. [4] Depending on the person, asthma symptoms may become worse at night or with exercise. [4] Asthma is thought to be caused by a combination of genetic and environmental factors. [3]
May also include herbal medications or nutritional supplements. May include data on dosage and compliance. past medical history (PMH) "none" Although remote childhood PMH is sometimes omitted, this information can sometimes be useful (for example, childhood asthma can be associated with adult atopic disorders.) past surgical history (PSH) "none"
GINA conducts continuous review of scientific publications on asthma and is a leader in disseminating information about the care of patients with asthma. [2] GINA publishes resources such as evidence-based guidelines for asthma management, and runs special events such as World Asthma Day. GINA's guidelines, revised each year, are used by ...
The information contained in the medical record allows health care providers to determine the patient's medical history and provide informed care. The medical record serves as the central repository for planning patient care and documenting communication among patient and health care provider and professionals contributing to the patient's care.
Evidence of care in a court of law. A legal record that can be used as evidence of events that occurred or treatments given. Show the use of the nursing process. It contains observations by the nurses about the client's condition, care, and treatment delivered. Provides data for quality assurance studies and shows progress toward expected outcomes.
Cardiac asthma is the medical condition of intermittent wheezing, coughing, and shortness of breath that is associated with underlying congestive heart failure (CHF). [1] Symptoms of cardiac asthma are related to the heart's inability to effectively and efficiently pump blood in a CHF patient. [ 2 ]