I need help with SOAP Please

[kwlkitty522]

A SOAP note is an organized way to document your visit findings. There are four parts:

S: Subjective – what the patient tells you, usually in quotations.

O: Objective – what you observe, be specific and objective.

A: Assessment – your conclusions/suspicions and assessment findings.

P: Plan – what actions are required, your plan.

S: I was in the hospital because my arthritis pain in my right hip got so bad I needed to get a new hip. Then I had all these problems. I fell because I couldn't reach my urinal and had to go back for more surgery. I also had trouble breathing and swallowing while in the hospital. They said I had some kind of pneumonia and a blood clot in my leg. This is all too much for my wife – I used to take care of her before all this happened. My daughter had to move in with us but she works and now my wife is taking care of my granddaughter and me. It's just too much for her.

O: Patient is a 74 year old male discharged home yesterday status post R THR (total hip replacement) eight days ago. A review of the hospital record indicated patient sustained a fall on post-op day 2 while trying to reach for his urinal during the night. He fell on his right hip and experienced excruciating pain. A follow-up xray revealed R hip displacement. Patient underwent revision. Hospital stay complicated by dysphagia, aspiration pneumonia, and RLE DVT. Note R hip incision well approximated, clean and dry, no redness or drainage noted. Also note R ankle decubitus stage III with moderate serosang drainage, no odor or redness noted. PMH: CHF, Type 1 DM for 10 years (patient reports he was independent in mgt prior to this hospitalization), a-fib, osteoporosis, osteoarthritis, hypothyroidism, HTN, hyperlipidemia, chronic depression, chronic anemia, COPD, BPH, constipation, bilateral cataracts. Past tobacco abuse (2 PPD x 60 years)(quit smoking several years ago), ETOH abuse consuming at least one six pack of beer per day.

Patient is homebound secondary to deconditioning and s/p R THR with revision, ambulates only 10 feet with wheeled walker, easily fatigued and SOB after 10 ft. Instruction re fall precautions and safe ambulation with walker.

Patient allergic to thermisol, paper tape, ASA. Pneumovax deferred secondary to aspiration pneumonia. Patient reports he does get seasonal flu vaccine annually and is interested in flu vaccine once it becomes available.

Patient lives with his wife, single daughter and 4 year old granddaughter in a 3-story townhouse with a bathroom on each level. Patient confined to 3^rd floor bedroom, BSC at bedside. Daughter works full time with erratic hours. Wife frail elder, ambulates with a walker. Wife overwhelmed with patient care needs. Patient was primary caregiver for wife prior to hospitalization. Patient and wife refused placement to rehab facility upon discharge from hospital.

Patient on multiple meds – see medication sheet. Medication issues noted. Daughter not available for insulin admin teaching, patient reports he is not able to self-administer sliding scale pre-meal insulin or HS insulin because I am too weak right now and don't want to make a mistake”, wife unable to do secondary to poor manual dexterity per wife report. Patient has not yet obtained prescriptions for Augmentin, Coumadin, or Lanoxin stating that daughter is supposed to get them today”. Instruction re importance of obtaining and starting these medications today. Instruction re actions of Augmentin, Coumadin and Lanoxin. Instruction on use of nebulizer and when to administer neb tx. Dr. Smith notified of visit findings and plan of care. He will call prescription for 70/30 insulin 20 units q am and 10 units q pm. Patient and wife advised accordingly.

ASSESSMENT:

PLAN:

[dishes, BSN, RN]

A. You need to do your own homework.

B. The information you posted contains unique information, I hope it is not based on a real patient's admission history.

[SnowShoeRN]

I would advise you to refrain from coming onto this site with a bunch of homework questions. You won't get a good response unless you give us some insight into your own thoughts and conclusions and ask for help (instead of just posting the question and making the thread title a statement that you need help). And, even then, there is no guarantee that 1. People will respond favorably and 2. Your answers will even be coming from nurses.

Best of luck in tackling the questions. Just use what assessment and planning incorporates, and their definitions, in order to formulate your own assessment and plan.

[traumaRUs, MSN, APRN]

Moved to nursing student assistance

[kwlkitty522]

I tried to get right back on after I posted w/o the second half I had for the Assessment and Plan and no not a real pt and I only wanted to see if I was on the right path. But thank you anyway

Assessment: (I was told keep it to a "one liner"

1) Increased risk for infection related to Impaired skin integrity manifested by a stage 3 decubitus on RLL

2) High risk fall alert related to recent fall, 2 days post op resulting in dislocation and revision on the right

hip. Pt reports of being weak.

3) Dyspnea on exertion related to COPD manifested by easily fatigued and SOB after 10 ft of ambulation.

PLAN:

1) Assess infection risks

Assess Right ankle decubitus characteristics and establish a baseline to mark changes

Monitor BS goal is Between 100 and 140 mg/dL for 60+ in age with other factors.

Monitor/Asses for changes to existing ulcer on RLL

Assess Cap refill, skin color, temp and pedal pulses

Evaluate if pt could use an Epi-pen. To increase compliance chances

Teach s/s of infection

2) Fall Prevention

Assess environment for fall hazards such as rugs, cords and texture differences

Provide adequate lighting

Make sure urinal is within reach

Ensure proper foot wear to prevent slipping

Confirm a source to reach help if needed. Pt is secluded to the third floor.

See if it's possible to move to the first floor for easier monitoring?

Teach changing positions slowly

Check HR and BP Pt hasn't been taking his Anti-coagulant Coumadin, or Afib medication, Lanoxin. Inform pt importance of medication compliance.

3) Activity Intolerance

Assist with ADL's

Plan activities with periods of rest in between.

Ax Lungs and administer nebulizer to help with the SOB

Monitor Oxygen saturation, skin color, temp and cap refill

Teach Purse Lipped Breathing

[sailornurse]

You have info in objective data that is part of subjective info. Objective data is only data you observe such as vital signs labs physical exam and anything else that is not part of that is subjective such as pmh lives with wife does. It belong in objective data in fact most of what you wrote the least few paragraphs are not objective.

[Kuriin, BSN, RN]

OP, you make no mention in your plan or assessment about the fact that this patient has heart failure, DVT, high cholesterol, AND a-fib. I understand that as a nursing student, people love "risk for falls," but our teacher ingrained into us that constantly using this diagnosis is shortcutting your learning.

You have an important one already: Infection. Patient has diabetes so poor wound healing (and probably poor control), plus he's got stage III ulcer.

Activity intolerance: Did you know this could be caused BY the CHF?

You also mentioned patient drinks 1 six pack of beer/day (with unknown length of time). Is this patient experiencing any withdrawal? Could he?

Work on your plan and assessment and we will guide you in the right direction.

[kwlkitty522]

You have info in objective data that is part of subjective info. Objective data is only data you observe such as vital signs labs physical exam and anything else that is not part of that is subjective such as pmh lives with wife does. It belong in objective data in fact most of what you wrote the least few paragraphs are not objective.

I was presented with that info by the teacher she set up the entire paper not a real person or case so there is no-one physically there to assess, But I see what you are saying about the objective and such. I was only asking about the Planning and Assessment part, I had to post a 2nd time to include those to be reviewed.

[kwlkitty522]

Not nice, but I understand why you would think that I had trouble trying to get logged back in to post the 2nd half of paper, which I was able to do. And not a real person or case I was confused on how to do an assessment on a person not in front of you and lastly not even homework I was curious b/c It would be for a future class and wanted to learn.

[sailornurse]

Not nice, but I understand why you would think that I had trouble trying to get logged back in to post the 2nd half of paper, which I was able to do. And not a real person or case I was confused on how to do an assessment on a person not in front of you and lastly not even homework I was curious b/c It would be for a future class and wanted to learn.

Please use the QUOTE button on the bottom left so we know who you are responding to.

[AliNajaCat]

https://allnurses.com/general-nursing-student/help-with-a-980953.h

Hi! Here's the summary answer about nursing diagnosis in general, which should get you going on the right path. Once you've read it (and gotten your NANDA-I 2015-2017), see what diagnoses you can make based on your assessment, and then ask us about it!

There is no magic list of medical diagnoses from which you can derive nursing diagnoses. There is no one from column A, one from column B list out there. Nursing diagnosis does NOT result from medical diagnosis, period. As physicians make medical diagnoses based on evidence, so do nurses make nursing diagnoses based on evidence.

You wouldn't think much of a doc who came into the exam room on your first visit ever and announced, "You've got leukemia. We'll start you on chemo. Now, let's draw some blood." Facts first, diagnosis second, plan of care next. This works for medical assessment and diagnosis and plan of care, and for nursing assessment, diagnosis, and plan of care. Don't say, "This is the patient's medical diagnosis and I need a nursing diagnosis," it doesn't work like that.

You don't "pick" or "choose" a nursing diagnosis. You MAKE a nursing diagnosis the same way a physician makes a medical diagnosis, from evaluating evidence and observable/measurable data.

This is one of the most difficult concepts for some nursing students to incorporate into their understanding of what nursing is, which is why I strive to think of multiple ways to say it. Yes, nursing is legally obligated to implement some aspects of the medical plan of care. (Other disciplines may implement other parts, like radiology, or therapy, or ...) That is not to say that everything nursing assesses, is, and does is part of the medical plan of care. It is not. That's where nursing dx comes in.

A nursing diagnosis statement translated into regular English goes something like this: "I'm making the nursing diagnosis of/I think my patient has ____(diagnosis)_____________ . He has this because he has ___(related factor(s))__. I know this because I see/assessed/found in the chart (as evidenced by) __(defining characteristics)________________."

"Related to" means "caused by," not something else. For example, "acute pain" includes as related factors "Injury agents: e.g. (which means, "for example") biological, chemical, physical, psychological." In many nursing diagnoses it is perfectly acceptable to use a medical diagnosis as a causative factor. You can thumb through your NANDA-I 2015-2017 and find lots and lots of medical diagnoses as related factors.

To make a nursing diagnosis, you must be able to demonstrate at least one "defining characteristic." Defining characteristics for all approved nursing diagnoses are found in the NANDA-I 2015-2017 (current edition). $39 paperback, $23 for your Kindle at Amazon, free 2-day delivery for students. This edition also includes an EXCELLENT FAQs section aimed at students.

NEVER make an error about this again---and, as a bonus, be able to defendappropriate use of medical diagnoses as related factors to your faculty. Won't they be surprised!

If you do not have the NANDA-I 2015-2017, you are cheating yourself out of the best reference for this you could have. I don't care if your faculty forgot to put it on the reading list. Get it now. Free 2-day shipping for students from Amazon. When you get it out of the box, first put little sticky tabs on the sections:

1, health promotion (teaching, immunization....)

2, nutrition (ingestion, metabolism, hydration....)

3, elimination and exchange (this is where you'll find bowel, bladder, renal, pulmonary...)

4, activity and rest (sleep, activity/exercise, cardiovascular and pulmonary tolerance, self-care and neglect...)

5, perception and cognition (attention, orientation, cognition, communication...)

6, self-perception (hopelessness, loneliness, self-esteem, body image...)

7, role (family relationships, parenting, social interaction...)

8, sexuality (dysfunction, ineffective pattern, reproduction, childbearing process, maternal-fetal dyad...)

9, coping and stress (post-trauma responses, coping responses, anxiety, denial, grief, powerlessness, sorrow...)

10, life principles (hope, spiritual, decisional conflict, nonadherence...)

11, safety (this is where you'll find your wound stuff, shock, infection, tissue integrity, dry eye, positioning injury, SIDS, trauma, violence, self mutilization...)

12, comfort (physical, environmental, social...)

13, growth and development (disproportionate, delayed...)

Now, if you are ever again tempted to make a diagnosis first and cram facts into it second, at least go to the section where you think your diagnosis may lie and look at the table of contents at the beginning of it. Something look tempting? Look it up and see if the defining characteristics match your assessment findings. If so... there's a match. CONGRATULATIONS! You made a nursing diagnosis! :anpom: If not... keep looking. Eventually you will find it easier to do it the other way round, but this is as good a way as any to start getting familiar with THE reference for the professional nurse.

About Risk for” diagnoses:

First: "Risk for" nursing diagnoses are very often properly placed first, as safety ranks above all of the physiological needs in Maslow's hierarchy. What are nurses for if not to protect a patient's safety?

Second: It is a fallacy that "risk for..." nursing diagnosis is somehow lesser or not "real" or "actual." If you look in your NANDA-I 2015-2017, there is a whole section on Safety, and almost all of the nursing diagnoses in that section are "risk for..." diagnoses. However, because NANDA-I has learned that nursing faculty is often responsible for this fallacy, the language on these has recently been revisited and was changed to include "Vulnerable to ..." in the defining characteristics the current edition.

Third: This sort of assignment is often made not only to see if somebody can recite rote information but to elicit your thought processes and see how well you can defend your reasoning. There is often no single priority; defend yours. Your faculty will be gratified to see you try to make your case.

Two more books to you that will save your bacon all the way through nursing school, starting now. The first is NANDA, NOC, and NIC Linkages: Nursing Diagnoses, Outcomes, and Interventions. This is a wonderful synopsis of major nursing interventions, suggested interventions, and optional interventions related to nursing diagnoses. For example, on pages 113-115 you will find Confusion, Chronic. You will find a host of potential outcomes, the possibility of achieving of which you can determine based on your personal assessment of this patient. Major, suggested, and optional interventions are listed, too; you get to choose which you think you can realistically do, and how you will evaluate how they work if you do choose them.It is important to realize that you cannot just copy all of them down; you have to pick the ones that apply to your individual patient. Also available at Amazon. Check the publication date-- the 2006 edition does not include many current NANDA-I 2015-2017 nursing diagnoses and includes several that have been withdrawn for lack of evidence.

The 2nd book is Nursing Interventions Classification (NIC) is in its 6th edition, 2013, edited by Bulechek, Butcher, Dochterman, and Wagner. Mine came from Amazon. It gives a really good explanation of why the interventions are based on evidence, and every intervention is clearly defined and includes references if you would like to know (or if you need to give) the basis for the nursing (as opposed to medical) interventions you may prescribe. Another beauty of a reference. Don't think you have to think it all up yourself-- stand on the shoulders of giants.