SOAP Detailed for Lactation Consultants

Patient Information: - Mother's Name: Sarah Johnson, ID: 123456, Date of Birth: 15 March 1990 - Infant's Name: Emily Johnson, Date of Birth: 20 October 2024 - Date and Time of the Nursing Assessment: 1 November 2024, 10:00 AM - Location: Room 305, Maternity Ward Subjective: - Chief Complaint/Reason for Visit: - Mom: Experiencing pain during breastfeeding and concerns about milk supply. - Baby: Poor weight gain and latch issues. Objective: - Infant Weights: - Infant Birth Weight [20 October 2024]: 7 pounds, 5 ounces - Infant Most Recent Weight [30 October 2024]: 6 pounds, 12 ounces - Infant Weight Today [1 November 2024]: 6 pounds, 14 ounces - Infant Weight Gain/Loss: 2 ounces gain over 2 days - Infant Percentage Below Birth Weight: 5% - Breastfeeding intake assessment: - Infant Prefeed Weight: 3200 grams - Left Breast Milk Transfer: 30 ml in 15 minutes - Right Breast Milk Transfer: 25 ml in 10 minutes - Infant Postfeed Weight: 3255 grams - Total Intake: 55 grams over 25 minutes, intake is improving - Breastfeeding exam: - Infant Feeding Affect: Calm - Gape: Wide - Orient: Easy - Depth: Deep - Infant Latch: Maintains grasp - Mother-Led: Yes - Feeding Position: Cradle - Cheeks: Against breast - Chin: Against breast - Lips: Upper and lower lip flanged out - Suck-Swallow Ratio: 1:1 for several minutes then variable - Infant suck: Consistent sucking - Coughing: None noted - Clicking: None noted - Choking: None noted - Increased Work of Breathing: None noted - Mom Ended Feed: No - Maternal nipple shape post feeding: Round - Infant After Feeding: Calm - Summary: Feeding examination shows a wide gape, with easy orientation and deep depth. Infant feeding affect is calm, and the feeding was mother-led. The feeding position was cradle, with cheeks and chin against breast. The suck-swallow ratio was 1:1. During feeding, no coughing, clicking, or choking were noted, with no increased work of breathing. The feed was ended by the infant, and the infant was calm. - Pumping Assessment: - Total pumping output: 100 ml in 20 minutes (Left: 50 ml, Right: 50 ml) - Flange Types Tried: Standard, Soft - Sizes of Each Flange Tried: 24mm, 27mm - Types of Pumps: Medela Pump In Style - Mom's Response: - Response to Each Pump: Comfortable with Medela - Response to Each Flange Size: Preferred 24mm - Response to Each Flange Type: Preferred soft flange - Summary: The mother expressed a total of 100 ml of breast milk in 20 minutes. She tried different flange types and sizes with various pumps. Her responses included comfort with Medela pump, preference for 24mm size, and soft flange type. - Supplemental feeding assessment: - Bottle Supplement: 30 ml formula, took 10 minutes to finish - At Breast Supplementer: Not used - Maternal Assessment: - Affect: Tired - Appearance: Well-appearing - Distress: Mild distress - Attachment to Infant: Normal - Breast exam shows medium breast size, not pendulous, and moderate glandular tissue. Breast consistency is normal, with areolas WNL and nipples normal. - Maternal Breast Assessment: - Breast Fullness: Normal - Density: Dense - Breast Size: Medium - Spacing: Normal - Pendulous: No - Elastic Tissue: Yes - Nipple Characteristics: Areola size 4 cm, nipple size 1.5 cm - Nipple pinch test: Erect - Areolas: WNL - Nipple damage: Normal - Nipple Measurement: Tip 1 cm, base 1.5 cm - Glandular Tissue: Moderate - Hypoplasia: Absent - Summary: The mother’s assessment reveals tired affect, well-appearing appearance, and normal grooming. No acute distress noted. Breast exam shows medium size, dense tissue, and normal spacing. - Infant Assessment: - Affect: Calm - Appearance: Well-appearing - Distress: No acute distress - Color: Normal - Skin: Warm, well-perfused - Hydration: Normal - Fontanels: Normal - Adipose Tissue: Normal - Tone: Normal - Symmetry: Symmetrical - Head Turning Preference: No preference - Summary: The infant presents with calm affect, well-appearing appearance, and normal development. No acute distress. The infant's skin is warm, and hydration status is normal. Fontanels are normal, with normal adipose tissue. Muscle tone and facial symmetry are normal. - Oral and Suck Exam: - Buccal Pads: Present - Lip Strength: Normal - Suck Strength: Normal - Tongue Cupping: Entire edge firm - Tongue Extension: Normal - Tongue Elevation: WNL - Tongue Lateralization: Complete - Gape: Wide - Palate: Normal shape - Motion: Normal - Gag Reflex: Normal - Lingual Frenulum: Normal - Lower Jaw: Normal - Summary: Oral and suck examination reveals present buccal pads, normal facial tone, and normal lip strength. The suck strength is normal, with tongue length normal and lift WNL. Palate is normal shape, with normal motion and gag reflex. The lingual frenulum is normal, and the lower jaw is normal. Assessment Summary: - Mom: Experiencing pain during breastfeeding and concerns about milk supply. - Baby: Poor weight gain and latch issues. - Lactation Consultant Assessment: - Overall assessment of lactation status, feeding effectiveness, maternal and infant well-being: The lactation status is improving with effective feeding techniques. Maternal and infant well-being are stable. - Billing Code: 99213 Plan: - Interventions and Education Provided: - Educated regarding flange fit - Educated regarding middle of the night milk removals - Educated regarding pump settings - Counseled parents regarding normal newborn feeding frequency - Latch and Positioning Support: - Provided guidance on asymmetrical latch techniques and optimal cradle positioning to improve breastfeeding effectiveness. - Maternal Comfort and Breastfeeding Techniques: - Discussed strategies to enhance maternal comfort, including breast compressions and relaxation techniques to support milk transfer. - Feeding and Pumping Guidance: - Advised on feeding patterns, recommended use of breast pumps, and discussed supplementation options. - Oral and Suck Assessment Findings: - Normal oral and suck assessment with no implications for breastfeeding. - General Breastfeeding Support and Follow-Up: - Provided additional breastfeeding support and discussed follow-up plan for next visit in one week. - Additional Notes: - Encouraged mother to maintain hydration and rest as needed.