Question

Using the following information to construct a SOAP note: Mrs. Puccini is a 65 year old female admitted 2 days ago with chronic bronchitis. Prior to hospitalization, she was complaining of fever, cough, and producing large amounts of yellow-green mucus for 5 days. She had smoked 1 1/2 packs of cigarettes per day since she was 18. Currently, she is using a nasal cannula at 1 LPM, her oxygen saturation is 92% and her pretreatment heart rate is 88 beats per minute. She is still complaining of cough and mucus production. You administer a nebulizer treatment with 0.5 mg ipratropium bromide diluted in 3.0 mL of normal saline. There are bilateral coarse crackles present before and after the treatment. She expectorates a moderate amount of yellow mucus after the treatment. Her saturation is still 92% and her heart rate is 110/min.

Answer 1

SOAP notes:
S- subjective - Subjective explain about the patient complaint, performance, and medical issues that cause the disease.
65 year old female admitted 2 days ago with a complaint of fever, cough, producing a large amount of yellow-green mucous for 5 days.
O- objective. there is a document about measurable outcomes about patient performance that provides quantitative information.
the patient has a smoking history of 1 1/2 packs of cigarettes per day since she was 18. bilateral coarse crackles present during admission. the patient is using 1lpm o2 through the nasal cannula.
A- assessment of client progress and performance,
   oxygen saturation 92%, heart rate 88beats per minute during pretreatment. the patient still complained of cough/mucous production.
P- plan.client treatment and a new plan for their goal.
Administer nebulizer 0.5mg ipratropium bromide dilutes in 3.0ml of NS.