IHUMAN CASE STUDY: EUNICE BLACK – COMPLETE SOAP
NOTE AND CAREGIVER-DIRECTED PATIENT EDUCATION
PLAN FOR DEHYDRATION IN A COGNITIVELY IMPAIRED
ELDERLY FEMALE
PART 1: PATIENT BIO DATA & INITIAL DATA GATHERING
Category Details
Name Eunice Black
Elderly (specific age not specified in available
Age
documentation)
Gender Female
Living
Skilled Nursing Facility (SNF)
Situation
Source Patient (limited) and caregivers
Limited – patient is AOx1 only (Alert and Oriented to pers
Reliability
only)
Allergies [To be confirmed]
Reason for Encounter: Dehydration
Chief Complaint: Unable to perform ADLs; requires assistance
with eating
, PART 2: PAST MEDICAL HISTORY (PMH)
Condition Details
Alzheimer's Presumed diagnosis (implied by cognitive impairment
Disease and need for caregiver education)
Dehydration Current admitting diagnosis
Cognitive AOx1 only (alert and oriented to person only; not to
Impairment place or time)
Key Points:
Patient is unable to perform ADLs independently
Requires assistance with eating
Dependent on caregivers for basic needs
PART 3: PHYSICAL EXAMINATION & MENTAL STATUS
Assessment Finding
Orientation AOx1 only – Alert and oriented to person only
ADL Status Unable to perform independently
Eating ability Requires assistance
Communication Limited; needs encouragement to verbalize needs
Cognitive Limitations:
Cannot orient to place or time
Limited ability to participate in own care
Dependent on caregivers for most ADLs
, PART 4: FINAL DIAGNOSIS
Primary Diagnosis
Dehydration
ICD-10: E86.0
Contributing/Comorbid Diagnoses
Diagnosis ICD-10 Rationale
Alzheimer's Impaired cognition leading to inability to
G30.9
Disease recognize thirst or independently seek fluids
Cognitive AOx1 status limits ability to participate in self
R41.89
Impairment care
Functional
R53.1 Unable to perform ADLs independently
Decline
PART 5: DISCHARGE/EDUCATION PRIORITIES
Question 1: Most Important Discharge/Education Priorities
Since the patient is unable to perform ADLs and requires
assistance with eating, education must focus on caregivers
rather than the patient. The following priorities will help prevent
future readmission:
NOTE AND CAREGIVER-DIRECTED PATIENT EDUCATION
PLAN FOR DEHYDRATION IN A COGNITIVELY IMPAIRED
ELDERLY FEMALE
PART 1: PATIENT BIO DATA & INITIAL DATA GATHERING
Category Details
Name Eunice Black
Elderly (specific age not specified in available
Age
documentation)
Gender Female
Living
Skilled Nursing Facility (SNF)
Situation
Source Patient (limited) and caregivers
Limited – patient is AOx1 only (Alert and Oriented to pers
Reliability
only)
Allergies [To be confirmed]
Reason for Encounter: Dehydration
Chief Complaint: Unable to perform ADLs; requires assistance
with eating
, PART 2: PAST MEDICAL HISTORY (PMH)
Condition Details
Alzheimer's Presumed diagnosis (implied by cognitive impairment
Disease and need for caregiver education)
Dehydration Current admitting diagnosis
Cognitive AOx1 only (alert and oriented to person only; not to
Impairment place or time)
Key Points:
Patient is unable to perform ADLs independently
Requires assistance with eating
Dependent on caregivers for basic needs
PART 3: PHYSICAL EXAMINATION & MENTAL STATUS
Assessment Finding
Orientation AOx1 only – Alert and oriented to person only
ADL Status Unable to perform independently
Eating ability Requires assistance
Communication Limited; needs encouragement to verbalize needs
Cognitive Limitations:
Cannot orient to place or time
Limited ability to participate in own care
Dependent on caregivers for most ADLs
, PART 4: FINAL DIAGNOSIS
Primary Diagnosis
Dehydration
ICD-10: E86.0
Contributing/Comorbid Diagnoses
Diagnosis ICD-10 Rationale
Alzheimer's Impaired cognition leading to inability to
G30.9
Disease recognize thirst or independently seek fluids
Cognitive AOx1 status limits ability to participate in self
R41.89
Impairment care
Functional
R53.1 Unable to perform ADLs independently
Decline
PART 5: DISCHARGE/EDUCATION PRIORITIES
Question 1: Most Important Discharge/Education Priorities
Since the patient is unable to perform ADLs and requires
assistance with eating, education must focus on caregivers
rather than the patient. The following priorities will help prevent
future readmission:
