NSG6440 Soap Note: Nursing SOAPS Example

Sample Soap Note of a Female Patient Presenting With Chronic Asthma

Demographics

Name: Rebecca Clarke                    Date: 16-July     Patient encounter number: 0549/19

Age: 19 years                                               Sex: Female

Subjective Data

CC: The patient says that “I have been coughing and having breathing difficulties since the beginning of winter. I always have shortness of breath and chest tightness during athletics competitions.”

HPI: The patient reports that she started experiencing shortness of breath and coughing three weeks ago when the winter season began. She states that when she is having shortness of breath, she produces a musical sound when breathing out. She started experiencing the symptoms since she was five years old when she was diagnosed with asthma. Since then, the symptoms have been intermittent lasting for more than an hour, and sometimes they get severe demanding emergency action. Besides, the symptoms mostly occur when exposed to cold or dust, and when she engages in vigorous activities such as athletics. The symptoms are relieved when she puffs an inhaler and rests. NSG6440 Soap Note: Nursing SOAPS Example

Medications: She has been taking Salbutamol and using a Beclomethasone inhaler to control and prevent asthma attacks.

PMH:  Was diagnosed with asthma at the age of 5 years. History of multiple admissions in the emergency department due to Asthmatic attacks. No history of surgery, blood transfusion, and major trauma. No history of other chronic illnesses.

Allergies: Allergic to penicillin, no known food allergy.

Sexual/ Reproductive history: She reports being sexually active. Menarche at 13 years, the menstrual cycle is regularly lasting for 3-5 days. L.M.P. 1-July-2019. Has one sexual partner. No history of S.T.I.s and denies contraceptives use. NSG6440 Soap Note: Nursing SOAPS Example

Family history: Father has H.T.N., and the mother is alive and well. All siblings are alive and well.

Social history: A 2^nd-year college student, who has a part-time job as a waiter in a local bar. She lives in a college hostel. She is the firstborn in a family of three. Reports that she occasionally consumes alcohol and denies tobacco smoking and drug abuse.

R.O.S.

General: Difficulty in breathing and shortness of breath.

Skin: Negative for skin rashes, discoloration, bruises, and bleeding.

HEENT: Head: Denies headache. Eye: Reports normal visual acuity, denies blurred vision or eye pain. Ear: Reports normal hearing, denies ear pain or discharge. Nose: Positive for nasal discharge, denies nose bleeding. Sinuses: Negative for facial pain or tenderness. Mouth: Denies dental pain. Throat: Negative for throat pain, difficulty in swallowing, and hoarseness.

Respiratory system: Positive for dyspnea (shortness of breath), non-productive cough, chest tightness, and difficulty in breathing.

Cardiovascular system: Chest pain and dyspnea on exertion. Denies heart palpitations and edema.

Gastrointestinal: Denies epigastric pain, vomiting, nausea, and abdominal cramps. Negative for diarrhea, blood in the stool, and constipation.

Endocrine: Denies excess thirst, weight loss, increased hunger sensation, and intolerance to heat or cold.

Genitourinary: Denies pelvic pain, abnormal vaginal discharge, urinary urgency, and pain during urination.

Musculoskeletal: Negative for muscle pain, muscle weakness, history of fractures, joint pain, or stiffness.

Neurological system: Negative for dizziness, seizures, fatigue, or numbness.

Objective Data

Vital signs: Temp- 98.6⁰ F, B.P- 118/78, Resp- 28 Pulse-130; SPO2- 88,Weight- 121 lbs. Height- 5’, BMI- 23.6.

General appearance: The patient is in respiratory distress, has an abnormal posture, and sits in a tripod position. Oriented to time, place, and person. Well-kempt and appropriately dressed.

Skin: Fair, moist, and warm skin with normal pigmentation. Normal skin turgor, no rashes, lesions, or bruises.

HEENT- Head: Symmetrical and normocephalic. Blonde hair with uniform distribution. Eye: Sclera white in color, pink conjunctiva, E.O.M.s intact, PERRLA, good visual acuity. Ear: Negative for ear discharge, ear wax present, tympanic membrane intact. Nose: Nasal septum well-aligned, positive for watery mucous discharge, no nasal flaring. Sinuses: non-palpable. Neck: Symmetrical, trachea well-aligned, neck veins engorged. Throat: Non-inflamed pharynx, no exudate, tonsillar glands non-erythematous, Thyroid gland is normal. NSG6440 Soap Note: Nursing SOAPS Example

Respiratory system: Chest and rise and falls unevenly during inhalation and exhalation. Use of accessory muscles during respiration with irregular respirations. On auscultation, wheeze, rales present and hyper-resonance, faint breath sounds.

Breasts: Normal pigmentation, nipple present with no discharge. No masses, lumps, and pain on palpation.

Cardiovascular: No ankle edema and jugular vein distension. Capillary refill 4 seconds. H.R at 128b/minute. S1 and S2 present; S3 and S4 absent.

Gastrointestinal: The abdomen is smooth, flat, and non-distended no lesions and scars. Abdominal muscle use during respiration. No tenderness on palpation, no hepatomegaly, and splenomegaly. Active bowel sounds perceived.

Genitourinary: Non-distended urinary bladder, and pelvic pain non-tender.

Musculoskeletal: Strong R.O.M., muscle strength, and normal muscle coordination.

Neurological: No nerve pain or numbness and a normal gait.

Special tests: ABGs:  HCO3- 24mEq/l, pH-7.4, PaO₂– 60 mmHg, PaCO₂-48 mmHg, O₂ Sat 88%.

Differential diagnosis

1. Status Asthmaticus: This is severe and persistent asthma characterized by exacerbations, which may result in hypoxemia and respiratory failure (Lambrecht & Hammad, 2015). The exacerbation can last for more than 24 hours, making it an emergency condition (Chakraborty & Basnet, 2018). It manifests with difficulty in breathing, long exhalation intervals, distended neck veins, and wheezing. Status Asthmaticus is a probable diagnosis based on positive subjective findings of a history of asthma, difficulty in breathing, and cough. Besides, objective findings of wheeze, engorged neck veins, use of accessory muscles, and irregular respirations make it a likely diagnosis.
2. Chronic Obstructive Pulmonary Disease (COPD): COPD presents with symptoms of a progressive, productive cough, which in some cases cause respiratory failure. There is also the use of abdominal accessory muscles during inhalation. On auscultation, rhonchi and wheeze are perceived. COPD is a likely medical diagnosis based on the patient’s positive findings of cough, shortness of breath, use of accessory muscles, wheezing, and abnormal breath sounds. However, there is a negative finding of a productive cough.
3. Bronchiolitis manifests with fever, tachypnea, tachycardia, fine rales, and fine wheezing. Severe cases of bronchiolitis cause respiratory distress characterized by a high respiratory rate, nasal flaring, and use of respiratory accessory muscles (Meissner, 2016). The patient also becomes cyanosed and is irritable. Bronchiolitis is a probable diagnosis based on positive findings of respiratory distress, tachycardia, rales, and wheezing. However, negative findings of fever and make it less likely to be the primary diagnosis.
4. Community-Acquired Pneumonia (CAP). CAP manifests with a productive cough, high body temperatures, tachycardia, nasal flaring, and use of respiratory accessory muscles. On auscultation, rales and abnormal Broncho-vesicular breath sounds are usually perceived (Prina, Ranzani, & Torres, 2015). CAP is a probable diagnosis as per the positive findings of rales, tachycardia, and use of accessory muscles. Nevertheless, wheezing is not a sign of CAP, and the patient has negative findings of fever, nasal flaring, and a productive cough. NSG6440 Soap Note: Nursing SOAPS Example

Primary diagnosis: Status Asthmaticus

Plan

1. Further diagnostic tests: Chest X-ray and a Lung CT-Scan to help in identifying anatomical anomalies of the lungs and presence of infections (Cloutier, 2016). Allergy tests to identify allergens that trigger asthmatic attacks. Provocative tests to measure the degree of airway obstruction during exposure to cold or physical activities (Lambrecht & Hammad, 2015). Sputum eosinophil’s test to establish the number of eosinophils in the saliva and mucus produced during cough. Lastly, pulmonary function studies are also important. NSG6440 Soap Note: Nursing SOAPS Example
2. Pharmacological interventions: This will aim at controlling inflammation and bronchoconstriction. They will be as thus:
3. Nebulization with Albuterol to relax the smooth muscles of the bronchi.
4. Beclomethasone inhalant 80mcg B.D., to relieve exacerbations, and improve airway patency (Lambrecht & Hammad, 2015).

• Prednisolone- decreases inflammation.

3. Non-pharmacological interventions: Positioning the patient in a semi-fowlers position to ease breathing. Oxygen therapy with humidified O₂ via a nasal cannula or mask to maintain adequate tissue perfusion and manage dyspnea and hypoxemia. I.V. fluid therapy with saline solution to maintain hydration (Cloutier, 2016).
4. Health education: Avoid causative agents such as cold and vigorous exercise. Adhere to the drug regimen and refrain from tobacco smoking. Intake of nutritious meals and adequate fluids to boost the immune system. Breathing exercises to decrease the amount of medication needed during asthma attacks (Cloutier, 2016). Engage in non-vigorous physical activities such as jogging, walking to maintain a healthy weight and improve the body’s immune system.
5. Follow-up. Follow-up by an immunologist for skin tests that identify the allergen that precipitates asthma exacerbations and guide allergen avoidance (Cloutier, 2016). NSG6440 Soap Note: Nursing SOAPS Example

References

Chakraborty, R. K., & Basnet, S. (2018). Status Asthmaticus. In StatPearls. StatPearls Publishing.

Cloutier, M. M. (2016). Asthma management programs for primary care providers: increasing adherence to asthma guidelines. Current opinion in allergy and clinical immunology, 16(2), 142-147.

Lambrecht, B. N., & Hammad, H. (2015). The immunology of asthma. Nature immunology, 16(1), 45.

Meissner, H. C. (2016). Viral bronchiolitis in children. New England Journal of Medicine, 374(1), 62-72.

Prina, E., Ranzani, O. T., & Torres, A. (2015). Community-acquired pneumonia. The Lancet, 386(9998), 1097-1108. NSG6440 Soap Note: Nursing SOAPS Example