SOAP Note

S: Pt reports pain at 3. Pt also reports numbness in R arm, but says it is slowly decreasing. Pt
reports last BM 2 days prior. Pt states she does not want additional laxative other than Colace.
Pt reports that she normally has 2 bowel movements per day. Pt reports that her husband is a
physician at EMC. Pt reports that her son is also a physician. Pt conveyed need to recover soon
because she has 4 grandchildren who keep her busy. Pt asked about which medications she was
being administered. Pt stated that having a physician as a husband allows her more knowledge
regarding her medications.
O: 64 yr old female A &O x 4. Pt calm and cooperative. Pt demonstrates good knowledge of
the medications she is taking and the amounts of each. Skin pale and with good turgor. Skin
warm and without moisture. PERRLA. Bandage covering R shoulder and down to R forearm.
No saturation visible on bandage. Muscle strength in L hand normal. Muscle strength in R hand
extremely weak. Limited ROM in R arm. Repirations even and unlabored. No cough present.
Bowel sounds hypoactive. Last BM two days prior. Urine clear, foley in place. Lung sounds all
clear. Heart rate regular at 85 bpm. S1 and S2 audible. Edema present in R upper extremity.
Pedal pulses 2+ bilaterally. NS infusing at rate of 125 mL/hr. Cap refill 2 seconds or less. Pt
condition is guarded. Activity- bedrest and up with one person assist. Pt on O2 therapy- 3L NC.
Pt on POD 1. Surgery performed on R humeral head due to fracture. Nerve block in place to
decrease pain. 36.8-85/53-18-85-92-3.
A: Muscle strength diminished in R arm due to recent fracture and follow-up surgery. Foley is
in place because pt is immobile. Pt experiencing constipation due to immobility and surgery.
O2 sats low, so pt was put on O2 therapy. Pt is guarded because her nerve block is dissipating
and she is in pain and frightened that her arm will be bumped or moved and more pain will
result. BP was low after administration of Losartan for her HTN.
P: Plan to inquire about physical therapy needs with discharge nurse. Muscle weakness is to
be expected on post op day one. Pt is to receive second surgery on 10/11 and will need
additional healing time before PT can be initiated. Colace administered for constipation. Plan to
continue to assess for BM. Norco administered for pain. Will reassess pain regularly and
monitor for medication needs. Will monitor BP q3mins until it returns to a normal level. Hold
Losartan until BP returns to pts normal level.

LA8/2011

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Student: Maggie Fabry

Course: 2nd semester clinical

Instructor: Mary Ann Johnston

Instructions: Please evaluate your performance today during clinical today using the following
concepts:
Patient Advocate
Critical Thinking
Self-Initiated
Safety
Leadership
Nursing Process

Professional Demeanor
Communication/ Rapport
Team Player
Organized
Well-prepared
Knowledgeable

Flexible
Peer Support
Skill Acquisition
Educator
Dependable

Areas of Strength Today (10/10)

Areas Needing Growth- Include Plan of

Improvement

Peer support- I helped Shelby on a number

Of different tasks today with her pt as well
As other pts on the floor. I also offered my
Help to multiple nurses on the floor.

Professional Demeanor- I demonstrate a

lack of confidence when I enter my pts
room. I am afraid that they have deemed
Me incapable the second I introduce
Myself as a student nurse. I need to give
both the pt and their family a sense of
Capability by walking in the room more
Assertively and confidently.

Safety- I practiced safe administration of meds

Today.
Skill Acquisition- Passed medications for the
First time today! I also connected a secondary
Line today and worked the infusion pump, which
I have only done one time previous.

LA8/2011

Educator- I have been lacking when it

comes to performing pt teaching. I need
To start providing my patients with more
Information and doing so confidently!

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