Heellllppp Quick Question

Well, if you have a plan, you must have built it around something, right? Go through each system, or whatever it is you assessing, then note things such as "Neuro: Alert, oriented X3. Musculoskeletal: Moves all extremities, full ROM. Respiratory: Lung sounds clear bilaterally, no respiratory distress noted. GI: Positive bowel sounds X4 quadrants; abdomen soft, nontender to palpation X4 quadrants. Skin: warm, dry, and intact."

Or whatever you do find that is normal for each system. I didn't cover everything but go over your assessment book for more clues.

Your question didn't specify what you were confused about..... maybe all of it?

S=subjective: what is the patient saying?

O=objective: what do you observe when you examine the patient?

A=based on the S & O, what is your assessment. Everything WNL might be the case, and you can list all your WNL findings.... But almost everybody has a little something.... a knowledge deficit, maybe? A desire for some improvement in functioning? The thing they are complaining about?

P=whatcha gonna do about the A?

That's pretty much it.

I'm surprised that, being a nursing student, you have a patient with no problems. Or is this maybe an assessment of a classmate, for practice....?

Good luck!

I agree with Chris that it all depends on what the pt is complaining about. There's got to be something you can find in your assessment of the pt or that the pt will tell you about himself/herself. Remember that your nursing diagnoses and care plans don't have to be about actual physical problems. If you go through the list in the NANDA book you're bound to find at least a few things that you can write up about any pt, even those that appear to be in reasonably good health.

The fact that the pt is seeking medical attn is automatically an opportunity to teach the pt something, so that's your knowledge deficit diagnosis right there. Was the pt anxious, nervous, or fearful about seeking medical attn or about the implications of becoming ill or requiring surgery? Most pts are, so that could be your psych diagnosis? As for the physical, the pt is in the hospital for a reason so you must be able to find something from your assessement that you can use. You mentioned skin, hair, and nails, but that's all external stuff. How about the internal body systems? What were the signs and symptoms that brought the pt to your hospital? Was the pt having pain? Any diabetes, pregnancy, HIV/AIDS? Anything at all that affects the pt's metabolic processes or changes in hormone levels? Any steroid use? Any over the counter or recreational drugs being used? Any high risk activities? Any noticeable recent changes in GI/GU function? Did you ask the pt how often they void/pass stools? And if there was anything unusual about the characteristics of the urine/stools? What about the pt's diet? Any drug/alcohol/tobacco use? What about the pt's lab values? Was everything WNL?

Alteration in any one body system has the potential to impact all the others so if you can find just one physical problem (risk or actual) its a given that you will find risks for others. Take another look at the "S" and "O" data in your SOAPIE.

What is the patient's diagnosis?

For SOAP Notes, what could be something you might put for a healthy person with no problems or complaints. Skin, hair, nails.. No problems ...what is the assessment. Plan is no problem but assessment has me stumped.

I beg anybodies help Thank you soooo much!!! :)