Instructions
SOAP Note Assignment
Create a SOAP note for disease prevention, health promotion, and acute care of the patient in the clinical case. Your care plan should be based on current evidence and nursing standards of care.
Visit the online library and research for current scholarly evidence (no older than 5 years) to support your nursing actions. In addition, consider visiting government sites such as the CDC, WHO, AHRQ, Healthy People 2020. Provide a detailed scientific rationale justifying the inclusion of this evidence in your plan.
Next determine the ICD-10 classification (diagnoses). The International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-10-CM) is the official system used in the United States to classify and assign codes to health conditions and related information.
Click here to access the codes (
https://www.cms.gov/medicare-coverage-database/search.aspx?error=Please%20use%20the%20new%20MCD%20Search%20to%20find%20documents%20with%20ICD-10%20codes.
).
Download the SOAP template to help you design a holistic patient care plan (Put in the dropbox below). Utilize the SOAP guidelines to assist you in creating your SOAP note and building your plan of care. You are expected to develop a comprehensive SOAP note based on the given assessment, diagnosis, and advanced nursing interventions. Reflect on what you have learned about care plans through independent research and peer discussions and incorporate the knowledge that you have gained into your patient’s care plan. If the information is not in the provided scenario please consider it normal for SOAP note purposes, if it is abnormal please utilize what you know about the disease process and write what you would expect in the subjective and objective areas of your note.
Week 2: Respiratory Clinical Case
Patient Setting:
65 year old Caucasian female that was discharged from the hospital 10 weeks ago after a motor vehicle
accident presents to the clinic today. States she is having severe wheezing, shortness of breath and
coughing at least once daily. She can barely get her words out without taking breaks to catch her breath
and states she has taken albuterol once today.
HPI
Frequent asthma attacks for the past 2 months (more than 4 times per week average), serious MVA 10
weeks ago; post traumatic seizure 2 weeks after the accident; anticonvulsant phenytoin started – no
seizure activity since initiation of therapy.
PMH
History of periodic asthma attacks since early 20s; mild congestive heart failure diagnosed 3 years ago;
placed on sodium restrictive diet and hydrochlorothiazide; last year placed on enalapril due to
worsening CHF; symptoms well controlled the last year.
Past Surgical History
None
Family/Social History
Family: Father died age 59 of kidney failure secondary to HTN; Mother died age 62 of CHF
Social: Nonsmoker; no alcohol intake; caffeine use: 4 cups of coffee and 4 diet colas per day.
Medication History
Theophylline SR Capsules 300 mg PO BID
Albuterol inhaler, PRN
Phenytoin SR capsules 300 mg PO QHS
HTCZ 50 mg PO BID
Enalapril 5 mg PO BID
Allergies
NKDA
ROS
Positive for shortness of breath, coughing, wheezing and exercise intolerance. Denies headache,
swelling in the extremities and seizures.
Physical exam
BP 171/94, HR 122, RR 31, T 96.7 F, Wt 145, Ht 5’ 3”
VS after Albuterol breathing treatment – BP 134/79, HR 80, RR 18
Gen: Pale, well developed female appearing anxious. HEENT: PERRLA, oral cavity without lesions, TM
without signs of inflammation, no nystagmus noted. Cardio: Regular rate and rhythm normal S1 and S2.
Chest: Bilateral expiratory wheezes. Abd: soft, non-tender, non-distended no masses. GU:
Unremarkable. Rectal: Guaiac negative. EXT: +1 ankle edema, on right, no bruising, normal pulses.
NEURO: A&O X3, cranial nerves intact.
Laboratory and Diagnostic Testing
Na – 134
K – 4.9
Cl – 100
BUN – 21
Cr – 1.2
Glu – 110
ALT – 24
AST – 27
Total Chol – 190
CBC – WNL
Theophylline – 6.2
Phenytoin – 17
Chest Xray – Blunting of the right and left costophrenic angles
Peak Flow – 75/min; after albuterol – 102/min
FEV1 – 1.8 L; FVC 3.0 L, FEV1/FVC 60%
Running head: NAME OF CARE PLAN
1
Title of Plan of Care
Name
South University Online
Faculty Name
NSG 6001
Date
NAME PLAN OF CARE
2
**Please delete this statement and anything in italics prior to submission to shorten the length
of your paper.
Patient Initials ______
Subjective Data: (Information the patient tells you regarding themselves: Biased Information):
Chief Compliant: (In patient’s exact words)
History of Present Illness: (Analysis of current problems in chronologic order using symptom
analysis [onset, location, frequency, quality, quantity, aggravating/alleviating factors, associated
symptoms and treatments tried]).
PMH/Medical/Surgical History: (Includes medications and why taking, allergies, other major
medical problems, immunizations, injuries, hospitalizations, surgeries, psychiatric history,
obstetric and history sexual history).
Significant Family History: (Includes family members and specific inheritable diseases).
Social History: (Includes home living situation, marital history, cultural background, health
habits, lifestyle/recreation, religious practices, educational background, occupational history,
financial security and family history of violence).
Review of Symptoms: (Review each body system – This section you should place POSITIVE for…
information in the beginning then state Denies…). – General:; Integumentary:; Head:; Eyes: ;
ENT:; Cardiovascular:; Respiratory: ; Gastrointestinal:; Genitourinary:; Musculoskeletal:;
Neurological:; Endocrine:; Hematologic:; Psychologic: .
Objective Data:
Vital Signs: BP – ; P ; R ; T ; Wt. ; Ht. ; BMI .
Physical Assessment Findings: (Includes full head to toe review)
HEENT:
Lymph Nodes:
Carotids:
Lungs:
Heart:
Abdomen:
Genital/Pelvic:
Rectum:
Extremities/Pulses:
Neurologic:
Laboratory and Diagnostic Test Results: (Include result and interpretation.)
Assessment: (Include at least 3 priority diagnosis with ICD-10 codes. Please place in order of
priority.)
Plan of Care: (Addressing each dx with diagnostic and therapeutic management as well as
education and counseling provided).
NAME PLAN OF CARE
3
References
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Formatting
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