Question

your assignment will be to do 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.

I will be grading on information provided, flow of your charting, all elements of a head to toe assessment were gathered as well as grammar.

This SOAPE note should be no more than 6 pages long and no less than 3 full pages.

Answer 1

The Subjective Objective Assessment, Plan and Expected outcome is a widely used method of documentation for health care providers. Each heading is described below:

Subjectve

It mainly includes subjective experiences, personal views or feelings of a patient / some one close to them. This section provides content for assessment and plan

a. Cheif complaint

The chief complaint or presenting complaint is reported by the patient. This can be a symptom, previous diagnosis or another short statement why the patient is presenting today

In this case: chief complaint is difficulty in breathing, decreased appetite or increased fatigue

b.History of present illness

It includes a single one line opening statement including patient's age, sex and reason for visit

e. Medical History: pertinent current or past medical conditions

f. surgical history: try to include the year of surgery and type and any complications after surgery

g. social history: details about patient's home, environment, education, employment, eating , activiites, drugs etc.

h. Current medications, history of allergies

Objective

This section involves the objective data from the patient encounter:

• General Appearance
• Vital signs
• Anthropometric measurements- height, weight
• Physical Examination findings
• Laboratory data
• Imaging results
• Other diagnostic data

General appearance and behaviour

Assess appearance and behaviour while preparing the patient for examination. For this review include:

• Gender and race
• Age
• Signs of distress: Shortness of breath, sternal retractions and anxiety
• Body type: Observe if the patient appears trim or muscular,obese or excessively thin. Body type reflects the level of health, age and lifestyle
• Posture
• Gait
• Body movements
• Hygiene and grooming
• body odor
• affect and mood
• Speech

Vital signs

Measurement of vital signs is more accurate before begining positional changes or movement. pain, considered as the fifth vital signs should be assessed

Height and weight

Reflects the patient's general health status. Ask the patient about his height and weight along with history of any substantial weight gain or loss . A wieght gain of 5 pounds(2.3 Kg) in a day indicates fluid retention. A weight loss is considered significant if he patient has lost more than 5% of body weight in a month or 10% in 6 months

Skin, hair and nails

The integumentary systm refers to skin, hair, scalp amd nails. Assessment of skin reveals the patient's health status related to oxygenation,circulation, nutrition, local tissue damage and hydraation. Skin color assessment first involves the areas that are not exposed to sun such as palms of the hand, soles of the feet, lips, tongue and nail beds

Inspect sites where abnormalities are easily identified such as:

• Pallor is most commonly evident in the face, buccal(mouth) mucosa,conjuctiva and nail beds
• Observe for cyanosis (bluish discoloration) in the lips, nail beds,palpebral conjuctiva and palms. In case of dark skinned patients,observe that normal brown skin appears to yellow brown and normal black skin appears to be ashen gray. Also assess lips, nailbeds and mucus membranes for genralized pallor; if pallor is present mucus membranes appear ashen grey
• assessment of dark skinned individuals by observing areas where pigmentation occurs least such as (buccal mucosa,conjuctiva, sclera, tongue, lips, nail beds, palms and soles

Moisture: the hydration of skin and mucus membranes helps to reveal body fluid imbalances, changes in the environment of the skin and the regulation of the body temperature. Assess for dullness, dryness, crusting,flaking of skin

Temperature: depends on the amount of blood circulatinh through the dermis. Increase or decrease in skin temperature indicates an increase or decrease of blood flow. A reduction in skin temperature often accompanies pallor and indicates a decrease in blood flow

Texture: Determine whether patient's skin is smooth or rough, thin or thick, tight or supple and indurated (hardened or soft)

Turgor: refers to the elasticity of the skin. Failure of skin to reassume its normal contour or shape indicates dehydration

Edema: Areas of skin become edematous or swollen with fluid accumulaton. Inspect edematous area for location, color and shape. Palpate edematous area for mobility, consistency and tenderness. assess for pitting edema

Hair and scalp

Inspect the color, texture, thickness and lubrication o body hair

Nails

Condition of nails reflect general health, state of nutrition, a person's occupation and habits of self care. Inspect the nail bed for color, length, symmetry, cleanliness and configuration. Shape and condition of the skin can give clues to the pathophysiological problems. Assess for thickness and shape of the nail, texture,angle between nail and nail bed. A larger angle and softening of nail bed indicates chronic oxygenation problem

Capillary refil should be checked to assess for adequate peripheral perfusion it should be less than 3 seconds more than that will be seen in patients with respiratory and cardiovascular diseases

Head and Neck

This includes examination of head,eyes,ears, nose, mouth,pharynx and neck(lymph nodes, carotid arteries, thyroid gland and trachea)

Head

Inspect the patient's head noting he size, shape and contour icluding facial featurs such as eye lids, eyebrows,nasolabial folds, mouth for shape and symmetry

Eyes

Visual acuity, visual fields, extraoccular movements, external and internal eye strucutres. Observe the pupils for size, shape,equality, accomodation and reaction to light. they are normall black,round,regular and equal in size (3-7 mm)

Ears

Ear assessment determines the integrity of ear structures and hearing acuity. inspect the opening of ear canal for size and presence of discharge. hearing acuity also should be assessed

Noses and sinuses

Assess the integrity of nose and sinuses using inspection and palpation

when inspecting for external nose, inspect for shape, size, color and presence of deformity or inflammation. Sinuses should be assessed for tenderness

Mouth and pahrynx

Lips: inspect the color, texture, hydration status.

teeth, buccal mucosa , tongue and floor of mouth should be properly inspected

Palate: observe the palate for color, shape, texture, extra bony prominces etc

Pharynx: assess for inflammation, infection or lesions

Thorax and lungs

Begin examination of posterior thorax of the patient. Observe for reduced mental alertness, nasal flaring, somnolence and cyanosis. Observe shape and symmetry from backa and front. Notr the anteroposterior diameter.

Ausculte and detect abnormal breath sounds- crackles, rhonchi. wheezes. friction rub

Inspect lateral and anteriot thorax for same features

Vascular system

Measurement of BP, pulse , heart sounds, assess for jugular venous destention

Assess the extremities for color, temperatue, pilse, edmea,skin changes and nail beds

Presnce of cyanosis requires immediate attention-blue lips, ear lobes and nail beds are signs of peripheral cyanosis

Clubbing of nails indicate peripheral cyanosis

Abdomen

Inspect for contour, symmetry , surface motion of the abdomen, noting any masses, bulging or distention. Auscultate for presence of bowel sounds , briut etc

Palpation primarly detects areas of abdominal tenderness , distention or masses

Genitourinary system

Detremine if patient had any genitourinary problems, including, burning during urination, frequency, urgency, nocturia,hematuria, incontinence etc

Evaluation/Outcome

The patient's skin is diaphoretic and warm to touch hence circulation is not compromised

But he have signs of central cyanosis, and peripheral cyanosis as ecvidenced by, his buccal mucosa appears ashen blue, eith blue and pale extremities and capillary refiling time is more than 3 sec which dmonstrates that he is expeiriencing hypoxemia(decreased oxygen saturation in the blood). These cardinal signs indicate that patient will go into acute respiratory distress state if not treated immediately. he is exhibiting signs of respiratory distress which requires immediate attention such as endotracheal intubation and mechanical ventilation to save his life