SOAP Nursing Care

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SOAP is a comprehensive documentation use by health care practitioners to write a systematic method of a patient history and physical. The information obtains from the patient complaint develop a diagnosis, plan, and medical management to health problems. The purpose of the assignment involves a comprehensive H&P that takes into considerate the patient signs and symptoms and formatting a plan of action, treatment and management in collaboration with the patient.
Patient Initials: K. K. Age: 48 Gender: Female
Chief Complaint: Fever and Lower Pelvic Pain
History of Present Illness: KK is 49-year-old Caucasian female two weeks S/P TLH present to the office with c/o lower pelvic …show more content…

Scalp and hair are wet and wave. Eyes: PERRLA with EOMs intact, active red reflex, sclera white in color, no cataracts or hemorrhage noted. Ears: Tympanic membrane patent, intact bilateral without bulging, no erythema or effusion noted. Nasopharynx: Patent, pink, moist oral mucosa, and no enlargement of nasal turbinates. Throat: soft and hard palate intact, non-tender, tonsils without enlargement, non-tender, and erythema Good dental hygiene.
Neck: AROM, no carotid bruit bilaterally,the trachea is midline, no nodules, lymph or thyroid enlargement or JVD.
Breast: No axillary lymph nodule enlargement, lumps, mass, or nipple discharge noted. Chest/Lungs: CTA in all fields without adventitious sound, chest movement symmetrical nonlabored breathing. Denies chest discomfort on palpation.
Heart/Peripheral Vascular: RRR, S1S2 at the apex, no S2S3 or murmurs heard on auscultation. Bilateral lower extremity edema. Capillary refills < 3sec, pink nail beds, radial and dorsalis pedis pulses palpate equal bilaterally.
Abdomen: Three Surgical lap site clean, dry, intact without drainage or signs of infection. Pain to the lower abdomen pelvic area on palpation. Soft, non-distended, normoactive bowel sounds in all four quadrants. No bruits heard. No hepatomegaly, mass, or splenomegaly on palpation.
Genital: No examination today. Will f/u in another two weeks unless patient c/o foul odor, or heavy vaginal …show more content…

Will f/u in another two weeks.
Musculoskeletal: All four extremities have AROM, no joint pain or stiffness observed with motor strength 5/5.
Neurological: Cranial nerves, I-XII intact without tremors. Intact balance and coordination saw during walking.
Mental status: Alert and oriented x4. Speech is clear, spontaneous and, precise. No distorted thinking or impaired judgment.
Psychiatric: Mood display feeling of worried, and concern happy, not easily distracted.
DIAGNOSTIC LAB TESTS:
CBC: Will reveal abnormal finding on the patient WBC indicating an infection.
CMP: Will reveal abnormal finding within the kidney and liver panel.
Urinalysis Analysis/ Urine Cultural: Checking abnormalities in the bladder.
Abdominal Ultrasound: Looks at varies body organs like they kidney, gallbladder, pancreas, spleen, liver checking for abnormal finding, and structure.
ASSESSMENT:
Urinary Tract Infection: “A urinary tract infection (UTI) is an infection in any part of your urinary system — your kidneys, ureters, bladder and urethra” (Mayo Clinic, 2017).
Cystitis: “is an inflammation of the bladder and is the most common site of UTI” (Huether & McCance,

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