NSG330 Health Assessment and Diagnostic Reasoning
Grading Criteria for Partner Complete Physical
Student Name:__________________________________________ Date:____________________
Format Possible Points Student’s Score
Paper is typed and turned in on time, with coversheet
5
Words in physical are selected by student and not copied directly from a textbook.
5
Content Possible Points Student’s Score
General Survey
10
Measurements
5
Head to Toe Examination
30
Assessment and Plan
Give 2 Nursing Diagnoses with at least two interventions for each
30
SOAP Note
15
Total 100 points Actual points =
Student may also use Chapter 28 in Jarvis textbook as guide and samples of a complete physical examination
—-
SOAP Note and Physical Examination
Stratford University’s NSG330 Health Assessment and Diagnostic Reasoning
SOAP Note and Physical Examination
M.S., M.S., M.S., M.S., M.S., M.S., M.S., M.S., M.S., M. Physical Exam Measurements: 36-year-old female Physical Exam Measurements: 36-year-old female
5’7″”””””””””” (170.18 cm)
170 pound weight (77.27 kg)
36-inch waist circumference
26.6 BMI
Signs of Life: BP: 150/90, HR: 54 bpm, RR: 10/min, and temperature: 97.9 F
General Questionnaire: Characteristics of the patient that are appropriate for her age and race. She is 36 years old and is not currently under the influence of any substances. The last time you used cocaine was two weeks ago. On February 15, 2020, she went to the ER with chest pain and SOB. She claims that the chest pain and SOB have improved in recent days. BP, HR, and RR are all high. She has SOB and chest pain that comes and goes. SOB improves with rest and deteriorates with physical activity. She is attempting to cut down on her smoking and cocaine use. She is currently residing in Woodbridge, Virginia, by herself.
Examination from head to toe
Skin color is ethnically acceptable, moist, and warm. Swelling, bruising, lesions, and a mole on the right face are not present. On the mole, nothing has changed. The patient claims that her skin has not changed.
Hair: Black, long, clean, and evenly distributed, as befitting her ethnicity. There are no lice or dandruff on my head.
Nails are of a normal color. She chews on her fingernail.
Capillary refills 5-6 seconds, nail bed is clean, beautiful, and firm.
No bumps and lumps, non-tenderness, dandruff, or lice on the head. Hair was examined and found to be in good condition, with no odor, no symptoms of alopecia, and the right hue for her ethnicity.
Face: Eyebrows and eyes are symmetrical, and there is no drooling or aberrant movement.
Symmetrical eyes with equal round PERRLA-Pupils that reacted to light and accommodation. Pupils have been narrowed by 2mm. There were no symptoms of jaundice, no drainage, a white sclera, and an eyelid that was within normal limits. Snellen chart vision acuity: Right and left 20/20, doesn’t wear contacts.
There is no hemorrhage or hematoma in the background of the eyes. There are vessels in all quadrants, but there are no crossing flaws.
Ear: Symmetrical, with no aberrant discharge, a patent appearance, and no wax build-up. Gray is the color of the tympanic membrane. Hearing is fine bilaterally, with both whispered and regular voices.
No deviated septum, discharge, bleeding, or lesions in the nose. During the sinus exam, there were no indicators of a sinus disease and no pain. Inner nose is non-tender and clean. The patient passes a sniff test, indicating that she is able to smell things normally. I used vanilla flavor as a test and was able to identify it.
Teeth are in good shape, the mucosa is pink, the tongue is pink, there are no lesions or ulcers in the mouth, gag reflux is present, and both tonsils are present. At the age of 17, all four wisdom teeth were extracted. Gums are pink and healthy, and there is no bleeding.
Neck: Straight neck line, with no trouble turning head right and left. A wide range of motion is available. Symmetrical, non-tender, without a tumor, lesions, or a rash PCP recommends starting steroid treatment for a little keloid under the chin. There is no discomfort in the lymph nodes. Trachea in the middle. During the exam, the thyroid was palpated and there was neither edema or soreness. Weak pulses 1+ were palpated in both carotid arteries at the same time.
No evidence of scoliosis or abnormal findings in the spine or back. There was no pain reported.
Thorax and Lungs: There is symmetrical chest enlargement, light crackling, and a wheezing sound. During coughing, mucus is present. There are no other unusual sounds.
Symmetrical breasts There are no dimples, discharge rashes, or lesions. There are no lumps or mases. Round and firm. Performs breast exams on a monthly basis.
S1 and S2 are both WNL. There was no heart murmur, and the apical pulse was matched with the radial pulse, indicating mild pulses 1+.
Contour checked, examination, auscultation, percussion, and palpation of all four quadrants, active bowel noises, last BM yesterday morning. During palpation, there is some mild pain.
Both upper and lower extremities have ROM. Good stamina. Color that is suited for the ethnicity of the patient. There was no edema, lesions, rashes, or bruises, and the skin was symmetrical. Peripheral pulses are reduced 1+. Pedal edema is seen. Upper and lower extremities are symmetrical. The patient said that there were no alterations on all of his extremities. Cap refills on toes took more than 3 seconds, and it took nearly 5 seconds. Skin that is cool and clammy.
Neck: mild soreness turning to the right. Musculoskeletal: Temporomandibular-within normal limits. Vertebral column: patient reports back ache for the past few days, with a minor curvature. Arms are symmetrical, with a bruising on the right forearm and complaints of carpel tunnel syndrome in both hands. Legs: symmetrical with each other, with a small amount of edema on both feet (non-pitting). Peripheral pulses have slowed. Muscle strength: Complains of carpal tunnel syndrome-related pain in the hands, as well as some trouble maintaining flexion and extension.
Neurologic: Mental status: LOC-alert and awake, avoiding eye contact, alert and orientated x3 (place, person, date), understanding and comprehending all that is being asked, clear voice, good hearing, clothed appropriately for the weather Intact cranial nerves II and III, good memories—was able to tell me why she came to the hospital. Sensory: able to distinguish my finger and pen touches on her face and arms. Stereotype: a cellphone’s touch was recognized. Motor: transferred the patient from the exam table to the chair, assessed the risk of a fall, and noted edema-related weakness in walking. Gait: little off-kilter, but tries to correct it. When the Romberg test is performed, the subject is unable to stand properly with their eyes closed. Balanced gait was a Cerebellar indication, yet she was able to follow the instructions to touch her mouth, ear, and eyes. DTRs are found in both the upper and lower extremities. +2.
External genitalia: slight rash on the right side—going to see a gynecologist next week—no open sores or cuts. Internal genitalia: normal color of vaginal wall, no symptoms of infection, no discharge, no bumps or lumps, cervical-nullipara os, no discharge. Papsmears are up to current as of 12/20/2019, and they are within normal limits. I have never been sexually active. LMP-12/28/2019. Menarchal age: 13 4 day duration 28 days each month
Bimanual examination: mild tenderness in right pelvic area; pelvic ultrasound will be ordered for further investigation; mudline uterus; no tumors or discomfort. Anus: constipation, emall external hemorrhoid; advised to drink plenty of water and fiber; no abnormal masses, lesions, or fissures. Rectal wall intact and patent, brown and soft feces, no blood on hemoccult test
Assessment
Smokes a lot of cigarettes and is addicted to cocaine (almost 2 packs a day)
Nicotine addiction
Uncontrolled high blood pressure, just diagnosed with CHF and dilated cardiomyopathy
Abuse of substances and nicotine
At the ED, I was recently seen for SOB and chest pain.
By 6-7 pounds, I’m slightly overweight.
Dental-Full sets of teeth were extracted at the age of 17, including all wisdom teeth.
There is a need for education concerning the use of cocaine and nicotine, as well as a recommended quit program/rehab.
Lonely, with few acquaintances and a strained relationship with family
The family resides in New York.
Doesn’t seem interested in quitting drugs or smoking cigarettes.
Coping technique that is ineffective
Nursing Diagnosis:
1. Chest pain, SOB, and weak peripheral pulses 1+ indicate a decrease in cardiac output due to changes in heart rate and rhythm, bloop pressure, and respirations. (Ackley and colleagues, 2017)
Plan: Before being discharged, the patient will show adequate cardiac output as evidenced by blood pressure, pulse rate, respiration rate, and rhythm being within normal parameters for herself; strong peripheral pulses; minimal edema; maintained level of mentation; and no chest discomfort, dyspnea, syncope, or chest pain. (Ackley and colleagues, 2017)
Plan: During the hospital stay and therapy, the patient will be free of adverse effects from the drug required to generate enough cardiac output. (Ackley and colleagues, 2017)
Plan: During her hospital stay, the patient will explain activities and safeguards to prevent primary and secondary cardiac illness, and she will participate in programs to quit smoking and cocaine. The information has been supplied. (Ackley and colleagues, 2017)
Identify tiredness, dyspnea, edema, orthopnea, paroxysmal nocturnal dyspnea, and elevated CVP as major symptoms indicating reduced cardiac output. Weight gain, hepatomegaly, jugular venous distention, lungs crackles, oliguria, coughing, clammy skin, and skin color changes are all secondary symptoms of low cardiac output. EBN: A nursing study to validate aspects of the nursing diagnosis of reduced cardiac out in a clinical setting discovered and classified client characteristics as primary or secondary (Martins et al, 2010)
Intervention 2: Before using cardiac drugs such angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, digoxin, or beta blockers, check your blood pressure, pulse, and overall health. If your heart rate or blood pressure is low, tell your doctor before you stop taking your prescriptions. Before delivering cardiac drugs, the nurse should assess how well the client is tolerating existing prescriptions; do not withhold medications without first consulting with a health care practitioner. Even if blood pressure or pulse rate have decreased, the health care professional may elect to provide drugs. (Ackley and colleagues, 2017)
Monitoring orthostatic blood pressure and daily weight is the third intervention. EB: The goal of this intervention is to determine the fluid volume status (Yancy et al, 2013).
2. Ineffective coping due to a lack of resources and social and personal support, as demonstrated by cocaine use, heavy smoking, living alone, having no friends, and not getting along with family, as well as family members living in New York. (Ackley and colleagues, 2017)
Plan: By the end of our therapeutic conversation, the patient will have identified emotions of isolation. (Ackley and colleagues, 2017)
Plan: After release, the patient will participate in activities and programs at her own pace and desire. (Ackley and colleagues, 2017)
Plan: The patient is urged to use therapeutic groups to reduce loneliness and stress; as a result, she will attend group or community therapy this weekend to apply effective behaviors to reduce loneliness and stress. The patient is given information on group and community treatment. (Ackley and colleagues, 2017)
Establish a therapeutic relationship with the client as the first intervention. EBN: Skingley (2013) notes in her study that many of the situations that contribute to social isolation are amendable, and that the community nurse is in a position to effect changes through one-on-one interventions, group activities, and community participation. EBN: Nurses are one of the most important client advocacy groups in the fight against social isolation (Wilson et al, 2011). (Ackley and colleagues, 2017)
Intervention 2: Encourage the client to express feelings such as grief, guilt, and anger (within appropriate bounds), communicate fears and concerns, and make goals using verbal and nonverbal therapeutic communication tools such as empathy, active listening, and confrontation. EBN: According to Ruddick (2011), solution-focused communication improves the identification of coping strengths and resources. (Ackley and colleagues, 2017)
Intervention 3: Assist the client in establishing realistic goals and determining personal abilities and expertise. EB: Adults (N=9) who were able to lose 10% of their body weight and maintain it for a minimum of 12 months differed from those (N=9) who were not successful at weight maintenance on factors like realistic goal setting, self-monitoring, and other effective coping skills, according to a qualitative study (Mckee et al, 2013). (Ackley and colleagues, 2017)
NOTE ON SOAP
Subjective: A 36-year-old woman clutches her chest and complains of chest discomfort on a scale of one to ten, with the SOB noting, “It really aches and I’m having difficulties breathing.” She claims that her chest is heavy and that she is in continual agony.
Observation: “I’m feeling chest pain and can’t breathe,” she says. V/S: 150/90 BP, 54 bpm HR, 10 bpm RR, 97.9 F, chilly and clammy skin Pulses in the periphery are weak 1+. Pedal edema and non-pitting are present. Slow cap refills.
Assessment: Decreased cardiac output related to alteration in heart rate and rhythm evidenced by chest pain and SOB.
Plan: Refer to physician for orders. Client goal-The client will demonstrate adequate output as evidence by heart rhythm within normal parameters or decrease of chest pain or relief from SOB after administering the medication as ordered.
Implementation: Called the doctor to notify the client’s status and request an order for nitroglycerine, administer it, and oxygen at 5 liters/minute via nasal cannula and ask for cardiac enzymes’ labs.
Evaluation: After 5 minutes, the client states the chest pain at 5/10 and decreasing and vital signs of heart rate 92 irregular rhythm, blood pressure 140/86, resp rate 16, oxygen saturation 96% on 5 liters oxygen via nasal cannula, skin is warm and dry, and states “I feel better.”
References
Jarvis, C., Eckhardt, A. (2020). Physical Examination and Health Assessment (8th Edition). Bloomington, Illinois.
Mackey, M.B., Ackley, B.J. (2017). Nursing Diagnosis Handbook. An Evidence-Based Guide to Planning Care. St. Louis, Missouri, USA: Elsevier.
—-
Physical Assessment and SOAP Note
NSG330 Health Assessment & Diagnostic Reasoning
Stratford University
Physical Assessment and SOAP Note
Patient name: M.S. DOB: 01/08/1984, Asian, Single. 36 years old female
Physical Examination
Measurements:
Height: 5 ft, 7 in (170.18 cm)
Weight: 170 lbs (77.27 kg)
Waist Circumference: 36 inches
BMI: 26.6
Vital Signs: BP-150/90, HR-54 bpm, RR-10/min, Temp-97.9 F
General Survey: Patient features appropriate for her age and ethnicity. She is 36 years old, not under any substance influences currently. Last cocaine use was 2 weeks ago. She went to ED for chest pain and SOB on 2/15/2020. She states that the chest pain and SOB has gotten better in a last few days. BP, HR, and RR elevated. She complaints of SOB and chest pain comes and go. SOB is better with resting and worsen with physical activities. She is making an attempt to minimize her smoking and cocaine use. She is currently living alone in Woodbridge, VA.
Head-To-Toe Examination
Skin: Color appropriate for the ethnicity, moist, and warm. No Swelling, bruises, lesions, mole on the right cheek. No changes on mole. Patient states no changes on her skin.
Hair: Appropriate for her ethnicity, black long, clean, and normal distribution. No lice or dandruff.
Nails: Normal color. She bites her nail.
Nail bed: Clean, nice and firm, capillary refills 5-6 seconds.
Head: No bumps and lumps, non-tender, no dandruffs, or no lice. Examined hair, good hygiene, no odor, no signs of alopecia, appropriate color for her ethnicity.
Face: Symmetrical eyebrows, eyes, no drooling or abnormal movements.
Eyes: Symmetrical, PERRLA-Pupil equal round and reacted to light and accommodation. Pupils constricted 2mm. No signs of jaundice, no drainage, white sclera, eye lid withing normal limit. Vision acuity by Snellen chart: Right and Left 20/20, doesn’t wear contacts.
Background of eyes have even color, no hemorrhage or hematoma. Vessels present in all quadrants without crossing defects.
Ear: Symmetrical, no abnormal drainage, patent, no build up waxes. Tympanic membrane is gray. Whispered voice and normal voice; hearing is good bilaterally.
Nose: No deviated septum, no drainage, not bleeding, no lesions. No signs of sinus problem, no pain during sinus exam. Non-tender, nice and clean inner nose. Patient passes smell test that she can smell things properly. Tested with vanilla flavor and was able to recognize the flavor.
Mouth: Teeth intact, pink mucosa, pink tongue, no lesions or sores in the mouth, gag reflux is present, both tonsils are present. All 4 wisdom teeth were removed at age 17. Gums are pink and looks healthy, no bleeding.
Neck: Straight neck line, able to turn head right and left without difficulty. Free range of motion. Symmetrical, non-tender, no mass, lesions, rash. Small keloid present underneath the chin and PCP recommend to start steroid treatment. No pain on lymph nodes. Midline Trachea. Palpated thyroid, no edema or pain during exam. Palpated carotid arteries simultaneously, weak pulses 1+.
Spine and Back: No signs of scoliosis, no abnormal findings. No pain reported.
Thorax and Lungs: Symmetrical chest expansion, light crackles and wheezing sound is present. Mucus present during cough. No other adventitious sounds.
Breasts: Symmetrical. No dimple, no discharge rashes, no lesions. No mases or lumps. Firm and round. Performs monthly breast exams.
Heart: S1 and S2 are WNL. No heart murmur, listened to apical pulse and matched with radial pulse, weak pulses 1+.
Abdomen: Contour checked, inspection, auscultation, percussion, and palpate all 4 quads, active bowel sounds, last BM yesterday morning. Mild tenderness during palpation.
Extremities: ROM present on both upper and lower. Good strength. Color appropriate to patient’s ethnicity. No edema, no lesions, rashes, bruises, and symmetrical. Diminished peripheral pulses 1+. Presence of pedal edema. Symmetrical upper and lower extremities. No changes stated on all extremities by patient. Slow cap refills on toes, more than 3 seconds, took about 5 seconds. Cool and clammy skin.
Musculoskeletal: Temporomandibular-within normal limit, Neck: slight pain turning to the right. Vertebral column: back pain for last couple of days stated by patient, slight curvature. Arms: symmetric with each other, bruise on the right forearm, complains of both hands’ carpel tunnel syndrome. Legs: symmetrical with each other, slight edema on the both feet (non-pitting). Diminished peripheral pulses. Muscle strength: Complains of pain on hands caused by carpel tunnel syndrome, slight difficulty on maintaining flexion and extension.
Neurologic: Mental status: Alert and oriented x3 (place, person, date), understanding and comprehending everything that is being asked, clear speech, good hearing, dressed appropriately for the weather, LOC-alert and awake, avoiding eye contact. Good memories-was able to tell me why she came to the hospital, Intact cranial nerves II and III. Sensory: able to recognize the touch made with my finger and pen on her face and arms. Stereognosis: recognized the touch made by a cellphone. Motor: moved the patient from the exam table to the chair, assessed risk for fall, slight weakness on walking due to edema. Gait: slightly imbalance but tries to balance it. Romberg test is performed and unable to stand properly when eyes are closed. Cerebellar sign: imbalanced gait; however, she was able to follow the instruction to touch mouth, ear, and eyes. DTRs: Present on upper and lower extremities +2.
Genitalia: External genitalia: small rash on the right side-following up with gynecologist
next week, no open sores or cuts. Internal genitalia: appropriate color of vaginal wall, no signs of infection, no discharge, no bumps or lumps, cervical-nullipara os, no discharge, within normal limit. Upto date for papsmear-12/20/2019-within normal limit, never been sexually active. LMP-12/28/2019. Age of menarch:13 duration:4 days frequency:28 days.
Bimanual examination: slight tender on the right pelvic area, will order for pelvic ultrasound for further evaluation, mudline uterus, no masses or pain. Anus: complains of constipation, emall external hemorrhoid-encouraged to intake adequate fluid and fiber, no abnormal mass, lesions or fissures. Rectal wall: Intact and patent, brown and soft stool-no blood found on hemoccult test.
Assessment
Cocaine dependent and smokes cigarettes heavily (almost 2 packs a day)
Nicotine dependence
History of uncontrolled HTN, recently diagnosed with CHF and dilated cardiomyopathy
Substance and nicotine abuse
Recently seen for SOB and chest pain at ED
Slightly over-weight by 6-7 lbs
Dental-Full sets of teeth, all wisdom teeth were removed at age 17
Need to educate about using cocaine and nicotine and recommended quit program/rehab
Lonely, doesn’t have lots of friends and doesn’t get along with family
Family lives in NY
Doesn’t show interest on quitting cocaine and cigarettes smoking
Ineffective coping mechanism
Nursing Diagnosis:
1. Decreased cardiac output related to altered in heart rate and rhythm, bloop pressure, and respirations evidenced by chest pain, SOB, and weak peripheral pulses 1+. (Ackley et al, 2017)
Plan: Patient will demonstrate adequate cardiac output as evidenced by blood pressure, pule rate, respiration rate and rhythm within normal parameters for herself; strong peripheral pulses; minimized edema; maintained level of mentation; lack of chest discomfort or dyspnea, syncope, or chest pain before getting discharge. (Ackley et al, 2017)
Plan: Patient will remain free of side effects from the medication used to achieve adequate cardiac output during hospital stay and while under treatment. (Ackley et al, 2017)
Plan: Patient will explain actions and precautions to prevent primary and secondary cardiac disease; therefore, she will take part in the programs to quit smoking and cocaine during the hospital stay. Information provided. (Ackley et al, 2017)
Intervention 1: Recognize primary characteristics of decreased cardiac output as fatigue, dyspnea, edema, orthopnea, paroxysmal nocturnal dyspnea, and increased CVP. Recognize secondary characteristics of decreased cardiac output as weight gain, hepatomegaly, jugular venous distention, lungs crackles, oliguria, coughing, clammy skin, and skin color changes. EBN: A nursing study to validate characteristics of the nursing diagnosis decreased cardiac out in a clinical environment identified and categorized related to client characteristics that were present as primary or secondary (Martins et al, 2010)
Intervention 2: Check blood pressure, pulse, and condition before administering cardiac medications such as angiotensin-converting enzyme inhibitor, angiotensin receptors blockers, digoxin, and beta blockers. Notify health care provider if heart or blood pressure is low before holding medications. It is important that the nurse evaluates how well the client is tolerating current medications before administering cardiac medications; do not hold medications without health care provider input. The health care provider may decide to have medications administered even though blood pressure or pulse rate has lowered. (Ackley et al, 2017)
Intervention 3: Monitor orthostatic blood pressure and daily weight. EB: This intervention assesses for fluid volume status (Yancy et al, 2013).
2. Ineffective coping related to inadequate resources and insufficient social and personal support evidenced by cocaine usage, heavy smoking, lives alone, not having friends and not getting along with family and family lives in NY. (Ackley et al, 2017)
Plan: Patient will identify feelings of isolation by the end of our therapeutic communication. (Ackley et al, 2017)
Plan: Patient will participate in activities and programs at level and desire once she is discharged. (Ackley et al, 2017)
Plan: Patient is encouraged to use the therapeutic groups to minimize the loneliness and stress; therefore, she will use effective behaviors to decrease loneliness and stress attending group or community therapy this weekend. Group and community therapy information provided to patient. (Ackley et al, 2017)
Intervention 1: Establish a therapeutic relationship with the client. EBN: In her study, Skingley (2013) suggests that many of the circumstances that contribute to social isolation and amendable that the community nurse in the position to affect changes by using one-on-one interventions, by involving the client in group activities, and by community engagement. EBN: Nurses are one of the fundamental client advocate groups that promote the prevention of social isolation (Wilson et al, 2011). (Ackley et al, 2017)
Intervention 2: Use verbal and nonverbal therapeutic communication approaches including empathy, active listening, and confrontation to encourage the client to express emotions such as sadness, guilt, and anger (within appropriate limits); verbalize fears and concerns; and set goals. EBN: Ruddick (2011) describes solution-focused communications as enhancing the identification of strength and resources of coping. (Ackley et al, 2017)
Intervention 3: Assist the client to set realistic goals and identify personal skills and knowledge. EB: In a qualitative study, adults (N=9) who were able to lose 10% of body weight and maintain the loss for a minimum of 12 months differed from those (N=9) who were not successful at weight maintenance on factors such as realistic goal setting, self-monitoring, and other effective coping skills (Mckee et al, 2013). (Ackley et al, 2017)
SOAP NOTE
Subjective: Patient is 36 years old female holding on her chest and complaining of chest pain 9 out 10 and SOB stating “It really hurts and having trouble breathing”. She states that chest feels heavy and having constant pain.
Observation: She states “I am having chest pain and can’t breathe,” V/S: BP-150/90, HR-54 bpm, RR-10/min, Temp-97.9 F, cool and clammy skin. Peripheral pulses are weak 1+. Presence of pedal edema and non-pitting. Slow cap refills.
Assessment: Decreased cardiac output related to alteration in heart rate and rhythm evidenced by chest pain and SOB.
Plan: Refer to physician for orders. Client goal-The client will demonstrate adequate output as evidence by heart rhythm within normal parameters or decrease of chest pain or relief from SOB after administering the medication as ordered.
Implementation: Called the doctor to notify the client’s status and request an order for nitroglycerine, administer it, and oxygen at 5 liters/minute via nasal cannula and ask for cardiac enzymes’ labs.
Evaluation: After 5 minutes, the client states the chest pain at 5/10 and decreasing and vital signs of heart rate 92 irregular rhythm, blood pressure 140/86, resp rate 16, oxygen saturation 96% on 5 liters oxygen via nasal cannula, skin is warm and dry, and states “I feel better.”
References
Jarvis, C., Eckhardt, A. (2020). Physical Examination and Health Assessment (8th Edition). Bloomington, Illinois.
Mackey, M.B., Ackley, B.J. (2017). Nursing Diagnosis Handbook. An Evidence-Based Guide to Planning Care. St. Louis, Missouri, USA: Elsevier.
—
As soon as possible, I need assistance with my nursing homework.
The following topics have been covered thus far:
In addition to the gastrointestinal (GI) system topics that we are reviewing this week, we will cover: subjective, objective, assessment, and plan (SOAP) notes; physical exams; history taking; head, eyes, ears, nose, and throat (HEENT); respiratory; and cardiovascular systems.
This week’s GI system topic will concentrate on the abdomen. The liver, spleen, intestines, pancreas, and stomach are all housed within the abdomen. Each year, abdominal issues cause millions of trips to the doctor’s office. This week, we’ll look at common GI issues in terms of the major complaint’s history, assessment findings, diagnostic testing, and differential diagnosis.
SOAP template
SOAP NOTE
Name: Date: Time:
Age: Sex:
SUBJECTIVE
CC:
Reason given by the patient for seeking medical care “in quotes”
HPI:
Describe the course of the patient’s illness, including when it began, character of symptoms, location
where the symptoms began, aggravating or alleviating factors; pertinent positives and negatives, other
related diseases, past illnesses, surgeries or past diagnostic testing related to present illness.
Medications: (list with reason for med )
PMH
Allergies:
Medication Intolerances:
Chronic Illnesses/Major traumas
Hospitalizations/Surgeries
“Have you every been told that you have: Diabetes, HTN, peptic ulcer disease, asthma, lung disease, heart
disease, cancer, TB, thyroid problems or kidney disease or psychiatric diagnosis.”
Family History
Does your mother, father or siblings have any medical or psychiatric illnesses? Anyone diagnosed with:
lung disease, heart disease, htn, cancer, TB, DM, or kidney disease.
Social History
Education level, occupational history, current living situation/partner/marital status, substance use/abuse,
ETOH, tobacco, marijuana. Safety status
ROS
General
Weight change, fatigue, fever, chills, night sweats,
energy level
Cardiovascular
Chest pain, palpitations, PND, orthopnea, edema
Skin
Delayed healing, rashes, bruising, bleeding or skin
discolorations, any changes in lesions or moles
Respiratory
Cough, wheezing, hemoptysis, dyspnea, pneumonia
hx, TB
Eyes
Corrective lenses, blurring, visual changes of any
kind
Gastrointestinal
Abdominal pain, N/V/D, constipation, hepatitis,
hemorrhoids, eating disorders, ulcers, black tarry
stools
Ears
Ear pain, hearing loss, ringing in ears, discharge
Genitourinary/Gynecological
Urgency, frequency burning, change in color of
urine.
Contraception, sexual activity, STDS
Fe: last pap, breast, mammo, menstrual
complaints, vaginal discharge, pregnancy hx
Male: prostate, PSA, urinary complaints
Nose/Mouth/Throat
Sinus problems, dysphagia, nose bleeds or
discharge, dental disease, hoarseness, throat pain
Musculoskeletal
Back pain, joint swelling, stiffness or pain, fracture
hx, osteoporosis
Breast
SBE, lumps, bumps or changes
Neurological
Syncope, seizures, transient paralysis, weakness,
paresthesias, black out spells
Heme/Lymph/Endo
HIV status, bruising, blood transfusion hx, night
sweats, swollen glands, increase thirst, increase
hunger, cold or heat intolerance
Psychiatric
Depression, anxiety, sleeping difficulties, suicidal
ideation/attempts, previous dx
OBJECTIVE
Weight BMI Temp BP
Height Pulse Resp
General Appearance
Healthy appearing adult female in no acute distress. Alert and oriented; answers questions appropriately.
Slightly somber affect at first, then brighter later.
Skin
Skin is brown, warm, dry, clean and intact. No rashes or lesions noted.
HEENT
Head is normocephalic, atraumatic and without lesions; hair evenly distributed. Eyes: PERRLA. EOMs
intact. No conjunctival or scleral injection. Ears: Canals patent. Bilateral TMs pearly grey with positive
light reflex; landmarks easily visualized. Nose: Nasal mucosa pink; normal turbinates. No septal deviation.
Neck: Supple. Full ROM; no cervical lymphadenopathy; no occipital nodes. No thyromegaly or nodules.
Oral mucosa pink and moist. Pharynx is nonerythematous and without exudate. Teeth are in good repair.
Cardiovascular
S1, S2 with regular rate and rhythm. No extra sounds, clicks, rubs or murmurs. Capillary refill 2 seconds.
Pulses 3+ throughout. No edema.
Respiratory
Symmetric chest wall. Respirations regular and easy; lungs clear to auscultation bilaterally.
Gastrointestinal
Abdomen obese; BS active in all 4 quadrants. Abdomen soft, non-tender. No hepatosplenomegaly.
Breast
Breast is free from masses or tenderness, no discharge, no dimpling, wrinkling or discoloration of the skin.
Genitourinary
Bladder is non-distended; no CVA tenderness. External genitalia reveals coarse pubic hair in normal
distribution; skin color is consistent with general pigmentation. No vulvar lesions noted. Well estrogenized.
A small speculum was inserted; vaginal walls are pink and well rugated; no lesions noted. Cervix is pink
and nulliparous. Scant clear to cloudy drainage present. On bimanual exam, cervix is firm. No CMT.
Uterus is antevert and positioned behind a slightly distended bladder; no fullness, masses, or tenderness.
No adnexal masses or tenderness. Ovaries are non-palpable.
(Male: both testes palpable, no masses or lesions, no hernia, no uretheral discharge. )
(Rectal as appropriate: no evidence of hemorrhoids, fissures, bleeding or masses—Males: prostrate is
smooth, non-tender and free from nodules, is of normal size, sphincter tone is firm).
Musculoskeletal
Full ROM seen in all 4 extremities as patient moved about the exam room.
Neurological
Speech clear. Good tone. Posture erect. Balance stable; gait normal.
Psychiatric
Alert and oriented. Dressed in clean slacks, shirt and coat. Maintains eye contact. Speech is soft, though
clear and of normal rate and cadence; answers questions appropriately.
Lab Tests
Urinalysis – pending
Urine culture – pending
Wet prep – pending
Special Tests
Diagnosis
Differential Diagnoses
o 1-
o 2-
o 3-
Diagnosis
o
Plan/Therapeutics
o Plan:
▪ Further testing
▪ Medication
▪ Education
▪ Non-medication treatments
Evaluation of patient encounter
