Question

a complete SOAPE note on our Covid-19 patient John.

Based off of John’s presentation and subjective data so far, begin your SOAP note.

You will need to complete a head to toe assessment based off his vital signs, and his presentation discussed in the scenario. As well as his skin and how it appears;

His skin is warm to the touch, and mildly diaphoretic.

His oral mucous membranes appear ashen, and slightly blue.

His perfusion is greater than 3 seconds on assessment.

His toes appear blue, ashen with a delayed cap refill.

Remember to include everything from his HEENT, to his chest and lungs, to his pulses and cap refill. His abdominal assessment and his GI/GU (you can be creative as you want to be with these body systems).

Carry on your assessment down to his lower extremities and what you think his reflexes would be.

Also, add what the evaluation or expected outcomes would be for John.

Do not forget if the patient was placed in isolation and any procedures that were put into place for John.

This SOAPE (E for evaluation or expected outcome) note should be very extensive and informative, as a nurse following your care, I should have an excellent picture of how John presented and what care was instituted to help him through his illness.

Answer 1

Physical Assessment

Integument

Skin: The customer's skin is uniform in shading, perfect and no nearness of any foul scent. His skin is warm to the touch, and somewhat diaphoretic.

Hair: The hair of the customer is thick, satiny hair is equally disseminated and has a variable measure of body hair. There are additionally no indications of contamination and pervasion watched.

Nails: The customer has a light earthy colored nails and has the state of arched bend. It is smooth and is unblemished with the epidermis. At the point when nails squeezed between the fingers (Blanch Test), the nails come back to normal shading in under 4 seconds.

Head

Head: The leader of the customer is adjusted; normocephalic and balanced.

Skull: There are no knobs or masses and sorrows when palpated.

Face: The substance of the customer seemed smooth and has uniform consistency and with no nearness of knobs or masses.

Eyes and Vision

Eyebrows: Hair is equitably appropriated. The customer's eyebrows are evenly adjusted and indicated equivalent development when requested to cause a commotion.

Eyelashes: Eyelashes gave off an impression of being similarly disseminated and twisted somewhat outward.

Eyelids: There were no nearness of releases, no staining and covers close evenly with automatic squints roughly 15-20 times each moment.

Eyes

The Bulbar conjunctiva seemed straightforward with not many vessels clear.

The sclera seemed white.

The palpebral conjunctiva seemed sparkling, smooth and pink.

There is no edema or tearing of the lacrimal organ.

Cornea is straightforward, smooth and sparkling and the subtleties of the iris are obvious. The customer squints when the cornea was contacted.

The understudies of the eyes are dark and equivalent in size. The iris is level and round. PERRLA (students similarly round react to light convenience), lit up and non-enlightened understudies chokes. Understudies contract when taking a gander at close to question and expand at far item. Understudies meet when item is moved towards the nose.

While evaluating the fringe visual field, the customer can see questions in the outskirts when looking straight ahead.

When testing for the Extraocular Muscle, according to the customer coordinately moved as one with equal arrangement.

The customer had the option to peruse the newsprint held a ways off of 14 inches.

Ears and Hearing

Ears: The Auricles are balanced and has a similar shading with his facial skin. The auricles are lined up with the external canthus of eye. While palpating for the surface, the auricles are versatile, firm and not delicate. The pinna withdraws when collapsed. During the evaluation of Watch tick test, the customer had the option to hear ticking in the two ears.

Nose and Sinus

Nose: The nose seemed symmetric, straight and uniform in shading. Having running nose. When daintily palpated, there were no delicacy and injuries

Mouth:

The lips of the customer are colourless; clammy, symmetric and have a rough surface. The customer had the option to press together his lips when requested to whistle.

Teeth and Gums: There are no staining of the polishes, no withdrawal of gums, pinkish in shade of gums

His oral mucous films seem colorless, and somewhat blue.

The tongue of the customer is midway situated. It is slightly whiteish in shading, clammy and somewhat unpleasant. There is a nearness of meager whitish covering.

The smooth palates are slightly bluish and smooth while the hard sense of taste has an increasingly sporadic surface.

The uvula of the customer is situated in the midline of the delicate sense of taste.

Neck:

The neck muscles are equivalent in size. The customer demonstrated facilitated, smooth head development with no uneasiness.
Having sore throat.
The trachea is set in the midline of the neck.

Chest, Lungs, and Abdomen

Lungs/Chest: Patient having difficulty in breathing, increase respiratory rate. Having dry cough with shortness of breath

The spine is vertically adjusted. The privilege and left shoulders and hips are of a similar tallness.

Heart: There were no obvious throbs on the aortic and pulmonic regions. There is no nearness of hurls or lifts.

Midsection: The mid-region of the customer has a perfect skin and is uniform in shading. The midsection has a symmetric shape. There were symmetric developments caused related with customer's breath.

The jugular veins are not noticeable.

His perfusion is more prominent than 3 seconds on appraisal. Patient is having diarrhea

Muscles: The muscles are not discernable with the nonappearance of tremors. They are regularly firm and indicated smooth, composed developments.

Bones: There were no nearness of bone disfigurements, delicacy and expanding.

Joints: There were no growing, delicacy and joints move easily.
Patient having fatigue and tiredness

His toes seem blue, gray with a postponed top off.

On the basis of all the above findings, this is a care plan, prepare for John

Nursing Diagnosis

In view of the appraisal information, the significant nursing determination for a patient with COVID-19 are:

• Disease identified with inability to maintain a strategic distance from pathogen optional to introduction to COVID-19.
• Inadequate information identified with newness to malady transmission data.
• Hyperthermia identified with increment in metabolic rate.
• Debilitated breathing example identified with brevity of breath.
• Uneasiness identified with obscure etiology of the infection.

Nursing Care Planning and Goals

Coming up next are the significant nursing care arranging objectives for COVID-19:

• Forestall the spread of contamination.
• Get familiar with the infection and its administration.
• Improve internal heat level levels.
• Reestablish breathing example back to ordinary.
• Diminish uneasiness.

Nursing Interventions

• Recorded beneath are the nursing mediations for a patient determined to have COVID-19:
• Screen essential signs. Screen the patient's temperature; the contamination for the most part starts with a high temperature; screen the respiratory pace of the patient as brevity of breath is another normal indication.
• Screen O2 immersion. Screen the patient's O2 immersion in light of the fact that respiratory trade off outcomes in hypoxia.
• Keep up respiratory separation. Keep tissues at the patient's bedside; arrange emissions appropriately; intsruct the patient to cover mouth when hacking or sniffling; use covers, and exhort those going into the space to wear veils too; place respiratory stickers on outline, cloths, etc.
• Uphold severe hand cleanliness. Encourage the patient and people to wash hands in the wake of hacking to decrease or forestall the transmission of the infection.
• Oversee hyperthermia. Utilize fitting treatment for raised temperature to keep up normothermia and lessen metabolic necessities.
• Teach the patient and people. Give data on infection transmission, analytic testing, illness procedure, intricacies, and security from the infection.

Assessment

Nursing objectives are met as prove by:

• Persistent had the option to forestall the spread of contamination.
• Quiet had the option to become familiar with the sickness and its administration.
• Persistent had the option to improve internal heat level levels.
• Persistent had the option to reestablish breathing example back to ordinary.
• Persistent had the option to lessen nervousness.

Documentation Guidelines

Documentation rules for a patient with COVID-19 incorporate the accompanying:

• Singular discoveries, including factors influencing, collaborations, nature of social trades, points of interest of individual conduct.
• Social and strict convictions, and desires.

Plan of care.

• Instructing plan.
• Reactions to mediations, instructing, and activities performed.
• Achievement or progress toward the ideal result.