Instructions: Select one of the topic mentioned below and discuses filling the attached form.
Topics:
Pneumonia
Requirements
Ø The discussion must address the topic
Ø Rationale must be provided
Ø Use at least 600 words (no included 1st page or references in the 600 words)
Ø May use examples from your nursing practice
Ø Formatted and cited in current APA 7
Ø Use 3 academic sources, not older than 5 years. Not Websites are allowed.
Ø Plagiarism is NOT permitted
attachment
SoapForm.docx
Soap Note # ____ Main Diagnosis ______________
PATIENT INFORMATION
Name:
Age:
Gender at Birth:
Gender Identity:
Source:
Allergies:
Current Medications:
·
PMH:
Immunizations:
Preventive Care:
Surgical History:
Family History:
Social History:
Sexual Orientation:
Nutrition History:
Subjective Data:
Chief Complaint:
Symptom analysis/HPI:
The patient is …
Review of Systems (ROS) (This section is what the patient says, therefore should state Pt denies, or Pt states….. )
CONSTITUTIONAL:
NEUROLOGIC:
HEENT:
RESPIRATORY:
CARDIOVASCULAR:
GASTROINTESTINAL:
GENITOURINARY:
MUSCULOSKELETAL:
SKIN:
Objective Data:
VITAL SIGNS:
GENERAL APPREARANCE:
NEUROLOGIC:
HEENT:
CARDIOVASCULAR:
RESPIRATORY:
GASTROINTESTINAL:
MUSKULOSKELETAL:
INTEGUMENTARY:
ASSESSMENT:
(In a paragraph please state “your encounter with your patient and your findings ( including subjective and objective data)
Example : “Pt came in to our clinic c/o of ear pain. Pt states that the pain started 3 days ago after swimming. Pt denies discharge etc… on examination I noted this and that etc.)
Main Diagnosis
(Include the name of your Main Diagnosis along with its ICD10 I10. (Look at PDF example provided) Include the in-text reference/s as per APA style 7th Edition. Make a paragraph
Differential diagnosis (minimum 4) make a paragraph for each one
PLAN:
Labs and Diagnostic Test to be ordered (if applicable)
· –
· –
Pharmacological treatment:
–
Non-Pharmacologic treatment:
Education (provide the most relevant ones tailored to your patient)
Follow-ups/Referrals
References (in APA Style)
___________________
Topic: Pneumonia
Rationale:
Pneumonia is a significant healthcare concern that affects a large number of individuals worldwide. It is crucial for healthcare professionals, especially nurses, to have a comprehensive understanding of pneumonia, its assessment, diagnosis, and management. By discussing the filling of the attached SOAP form for a patient with pneumonia, we can explore the essential aspects of this condition, including subjective and objective data, assessment, diagnosis, and the development of an appropriate plan of care. This discussion will help nurses enhance their knowledge and skills in managing patients with pneumonia effectively.
Soap Note # ____ Main Diagnosis ______________
PATIENT INFORMATION
Name:
Age:
Gender at Birth:
Gender Identity:
Source:
Allergies:
Current Medications:
PMH:
Immunizations:
Preventive Care:
Surgical History:
Family History:
Social History:
Sexual Orientation:
Nutrition History:
Subjective Data:
Chief Complaint:
Symptom analysis/HPI:
The patient is …
Review of Systems (ROS) (This section is what the patient says, therefore should state Pt denies, or Pt states….. )
CONSTITUTIONAL:
NEUROLOGIC:
HEENT:
RESPIRATORY:
CARDIOVASCULAR:
GASTROINTESTINAL:
GENITOURINARY:
MUSCULOSKELETAL:
SKIN:
Objective Data:
VITAL SIGNS:
GENERAL APPEARANCE:
NEUROLOGIC:
HEENT:
CARDIOVASCULAR:
RESPIRATORY:
GASTROINTESTINAL:
MUSCULOSKELETAL:
INTEGUMENTARY:
ASSESSMENT:
(In a paragraph please state “your encounter with your patient and your findings ( including subjective and objective data)
Example: “Pt came in to our clinic c/o of ear pain. Pt states that the pain started 3 days ago after swimming. Pt denies discharge, etc. On examination, I noted this and that, etc.)
Main Diagnosis
(Include the name of your Main Diagnosis along with its ICD10 I10. (Look at PDF example provided) Include the in-text reference/s as per APA style 7th Edition. Make a paragraph
Differential diagnosis (minimum 4) make a paragraph for each one
PLAN:
Labs and Diagnostic Test to be ordered (if applicable)
· –
· –
Pharmacological treatment:
–
Non-Pharmacologic treatment:
Education (provide the most relevant ones tailored to your patient)
Follow-ups/Referrals
References (in APA Style)
Subjective Data:
In the subjective data section, the nurse would document the patient’s chief complaint and the symptom analysis/history of present illness. For a patient with pneumonia, the chief complaint could be cough, chest pain, difficulty breathing, fever, or general malaise. The nurse would gather information on the onset and duration of symptoms, associated factors such as exposure to sick individuals or recent travel, and any alleviating or aggravating factors.
Review of Systems (ROS):
In this section, the nurse would document the patient’s responses to questions related to different body systems. For pneumonia, relevant ROS findings may include:
Constitutional: Fever, fatigue, chills.
Neurologic: Headache, confusion.
HEENT: Sore throat, sinus congestion.
Respiratory: Cough, shortness of breath.
Cardiovascular: Chest pain, rapid heart rate.
Gastrointestinal: Nausea, vomiting, abdominal pain.
Genitourinary: No specific findings related to pneumonia.
Musculoskeletal: No specific findings related to pneumonia.
Skin: No specific findings related to pneumonia.
Objective Data:
The objective data section includes the physical examination findings and vital signs. For a patient with pneumonia, the nurse would assess the following:
Vital Signs: Temperature, heart rate, respiratory rate, blood pressure, and oxygen saturation. Fever, increased heart rate, increased respiratory rate, and low oxygen saturation may be present.
General Appearance: The patient may appear fatigued, ill, or in distress.
Neurologic: The nurse would assess mental status, level of consciousness, and neurological function.
HEENT: Examination of the head, ears, eyes, nose, and throat may reveal signs of upper respiratory infection, such as redness or congestion.
Cardiovascular: The nurse would listen to heart sounds and assess for any abnormal findings.
Respiratory: The nurse would auscultate the lungs for abnormal breath sounds, such as crackles or decreased breath sounds.
Gastrointestinal: Examination of the abdomen for tenderness or distension.
Musculoskeletal: Assessment of mobility and any limitations related to respiratory distress.
Integumentary: No specific findings related to pneumonia.
Assessment:
Based on the subjective and objective data, the nurse would provide an assessment of the patient’s condition. This would involve summarizing the encounter with the patient, including findings and observations. For example, “The patient presented to the clinic with a chief complaint of cough, chest pain, and fever. On examination, the patient had a temperature of 101°F, increased respiratory rate, and crackles heard on lung auscultation. These findings are consistent with a diagnosis of pneumonia.”
Main Diagnosis:
The main diagnosis section would include the name of the main diagnosis along with its ICD-10 code. The specific diagnosis would be determined based on the patient’s symptoms, physical examination, and any additional diagnostic tests. For example, the main diagnosis could be “Community-acquired pneumonia (CAP)” with the ICD-10 code J18.9 (Pneumonia, unspecified organism).
Differential Diagnosis:
The nurse would provide a paragraph for each of the differential diagnoses considered. Differential diagnoses for pneumonia could include:
Acute bronchitis: This condition presents with similar respiratory symptoms but usually lacks the focal lung findings seen in pneumonia.
Influenza: Influenza infection can cause respiratory symptoms and fever, but it typically lacks the localized lung findings.
Pulmonary embolism: This condition may present with respiratory symptoms and chest pain, but there may be a history of recent immobilization or risk factors for deep vein thrombosis.
Asthma exacerbation: Patients with asthma may experience similar symptoms, but there may be a history of chronic respiratory disease and a different pattern of physical examination findings.
PLAN:
In the plan section, the nurse would outline the necessary steps for managing the patient’s pneumonia. This may include ordering labs and diagnostic tests, pharmacological and non-pharmacological treatments, patient education, and follow-ups/referrals.
Labs and Diagnostic Tests:
Appropriate labs and diagnostic tests for pneumonia may include:
Complete blood count (CBC) with differential
Chest X-ray
Sputum culture and sensitivity (if productive cough)
Pulse oximetry or arterial blood gases (ABGs) to assess oxygenation
Pharmacological Treatment:
The pharmacological treatment for pneumonia would depend on various factors such as the suspected causative organism, severity of symptoms, and patient-specific considerations. Commonly prescribed antibiotics for community-acquired pneumonia may include:
Azithromycin
Amoxicillin-clavulanate
Ceftriaxone
Levofloxacin
Non-Pharmacologic Treatment:
Non-pharmacological treatments for pneumonia may include:
Adequate hydration
Rest and adequate sleep
Steam inhalation or humidification
Chest physiotherapy or deep breathing exercises
Education:
Relevant patient education for pneumonia may include:
Explanation of the diagnosis, its causes, and treatment plan
Importance of completing the full course of antibiotics
Techniques for coughing and deep breathing exercises to aid lung clearance
Recognition of worsening symptoms and when to seek medical attention
Strategies for infection prevention, such as hand hygiene and covering the mouth and nose when coughing or sneezing
Follow-ups/Referrals:
The nurse may indicate any necessary follow-up appointments with the primary care provider or referrals to specialists, such as pulmonologists, if required.
