Kylastanleyonline.files.wordpress.com



King University MSN/NP Program 42386250Clinical SOAP Note Format PediatricsStudent Kyla Stanley Course NURS5023SOAP Note #1Pt. Initials: CP Age: 8 DOB:00/29/2009 LMP N/A Allergies NKDAImmunization status: Up to DateMedications: OTC Ibuprofen and Acetaminophen PRN for fever and painErickson’s Developmental Stage: 4 Industry vs Inferiority (ages 5-12) In this stage children begin to flourish in academics and teachers begin to play an important role in the child’s life. The child strives for approval of their peers and develop a sense of pride for their accomplishments.(S)Chief Complaint: Pain and swelling of left great toe x 3 daysHPI: Onset- 3 days agoLocation- Left great toeDuration- Intermittent pain which worsened since day 1Character- aching/throbbing pain to affected toeAggravating/Associated- pain is worsened with ambulation and palpation of toeRelieving- pain is lessened when foot is ambulatedSeverity- 7/10 with ambulation 4/10 when at restHistory:Prenatal/birth history/medical history- CP was born full-term with a birth weight of 7lb 3oz. He was born by vaginal birth with no complications. His mother obtained routine prenatal care which began at 11 weeks gestation. Surgical Hx- No surgical history Social Hx- CP has several friends at school and seems to be socially accepted. He is drawn to his grandmother and strives to make her proud. He enjoys playing video games and riding his bicycle. Family Hx- Paternal Grandmother- hx of diabetes and COPD, Maternal Grandmother- Obesity and Hypertension. Paternal Grandfather- COPD, Hypertension and Congestive Heart Failure, Maternal Grandfather deceased at age 51 due to MVA. Father has Hypertension and Depression, Mother is healthy with no significant health history.ROS: General- No fatigue, fever or chills. Denies difficulty sleeping or night sweats.HEENT- Head: Denies headaches or trauma. Eyes: Last eye exam was July 2017, denies redness, itching or discharge. Pt states he sees the blackboard easily in school and has no blurriness. Ears: Pt has history of recurrent inner ear infections and is followed by ENT closely. He does not have any difficulties in hearing.Nose: Pt has history of seasonal allergies and Rhinitis which is worsened in the Spring season. Symptoms usually resolve with weather changes. He denies nasal congestion at this time, nosebleeds or trauma.Throat: Last dental exam was July 2017. He has a history of dental caries which are treated. Denies sore throat, hoarseness or vocal changes.Skin- Denies rashes, hives, changes is coloration or sizing of moles or lesions. Respiratory- Denies cough, SOB, hemoptysis or difficulty breathing. Cardio- Pt denies palpitations, chest pain or discomfort or orthopnea. GI- Denies changes in bowel habits, abdominal pain or discomfort, heartburn or reflux.GU- Denies any changes in urination. Denies painful urination, hematuria, hesitancy, incontinence, flank pain, or odor of urine. Diet- CP enjoys eating pizza, chicken nuggets, hamburgers and French fries. His mother states that he has been trying new foods lately and has began enjoying having some vegetables added to his meals. He usually has oatmeal or a pop-tart for breakfast. He has school lunches but she states that she packs his lunch appx 2-3 days a week depending on the school menu. For snacks he eats apples, peanut butter, snackables or chips. The family has a meat, a starch and 2 vegetables for dinner and eat outside the home appx 2 days a week. Endocrine- Denies heat/cold intolerance, excessive sweating, increased thirst or polyuria.MS- Denies history of fractures, sprains or strains. No complaints of pain or stiffness in joints, muscle cramps, or weakness. He has no history of scoliosis or deformities.Neuro- No complaints of syncopal episodes, weakness, paralysis, unsteady gait, loss of memory, paralysis, disorientation, speech disorders, headaches, loss of taste of smell or taste or tremors. Pt has no history of ADHD or ADD behavioral disorders. Psych- Mother states there have been no changes in mood, depression, hallucinations, psychiatric disorders or suicidal/homicidal tendencies. (O)Vital signs: T: 97.8 P: 105 R: 18 BP: 107/61 HT: 4ft 6in WT: 104 BMI: 25.1 Pain: 6/10Percentile on growth chart: WT: 99th HT: 91st HC: 21in (*attach growth chart)Growth ChartDevelopmental status: CP has met and exceeded all of his developmental milestones. He is able to problem solve independently and takes initiative to complete tasks without being asked. His mother states that he has been showing interest in cooking and has made some dishes independently with supervision. He is doing well in school and is top of his class in reading and mathematics.Constitutional – Alert and oriented x 3, well nourished and developed. He is cooperative and able to verbalize his complaints. He is clean and dressed appropriately. Head- Atraumatic, normocephalic, no tenderness verbalized upon palpation. Free of lesions or lumps. Facial features symmetrical without weakness.Eyes- No presbyopia, PERRLA, EOMI, structures without lesions noted, sclera white, cornea clear, red reflex present, conjunctiva pink. No discharge, excessive tearing or photophobia.Ears- No lesions noted to external structures, no tenderness on retraction of pinnae. TMs are pearly gray with limited light reflex. Some scarring noted to L TM related to previous OM. Canals have mild dark yellow cerumen bilaterally. Nose- Symmetrical without evidence of septal deviation or trauma. Nares patent, turbinates intact. Mucosa is pink and with clear discharge present. No sinus tenderness, sinuses trans illuminate equally bilaterally.Throat- Oropharynx without erythema, clear exudate noted. Uvula is midline and rises symmetrically, gag reflex intact. Lymph- Supple and non-tender with palpation. Thyroid is not enlarged and without nodularity and trachea is midline. No lymphadenopathy to submandibular, auricular, pre-auricular, supraclavicular, occipital, parotid, submental, axillary, inguinal region.Skin- No lesions or abnormal mole/nevi noted. Normal/light hair distribution to head and arms visible. Small scratch to L hand noted but healing appropriately. L great toenail is ingrown with visible erythema with mostly purulent and serosanguinous fluid draining from lateral aspect of nail bed. Nail appears irregular and jagged. Chest/Lungs- Breath sounds are clear to auscultation in all quadrants. Symmetrical chest expansion, respirations are non-labored and with regular pattern and without distress. Heart/pulses- RRR, without murmur, rub, gallop, thrill, or clicks. S1, S2, No abdominal pulsations, lifts, or heaves noted. Capillary refill <2 sec with distal pulses bilaterally. Abdomen- Abdomen is soft, non-tender, non-distended with normoactive bowel sounds heard in all four quadrants. No guarding with palpation or masses noted. No CVA tenderness. Genitalia (with Tanner staging)- N/AMusculoskeletal- Steady gait, muscle strength 5/5 to all groups, Full ROM, no deformities noted. Spine with full ROM and no scoliosis noted. Neurological- Alert and oriented with no obvious mental status deficits observed. Cranial nerves II-XII grossly intact and strong tone noted to all extremities. Deep tendon reflexes intact to upper and lower extremities 2+ Psych- Cooperative and maintains eye contact throughout exam. Pt is alert and interactive with behaviors appropriate for age. (A)Dx: (include ICD 10 code - )(list as many diagnoses as indicated)Onychocryptosis L60.0Allergic Rhinitis J30.9BMI 25.1 Z68.54Differentials:1.Cellulitis L03.902-Superficial Foreign Body S90.852A3-Acute Sinusitis J01.00(P) Tests/Labs/Diagnostics- (Include costs of tests, medications*) Treatment Plan- Keflex 500mg 1 tablet by mouth twice daily for 10 days $9-12 but full coverage of pt insurance-no out-of pocket cost.Pt advised to use otc antibiotic ointment as needed- encouraged tidIbuprofen or Acetaminophen otc as needed for pain. Parent/Patient Education- Mother advised to have pt soak toe/foot in warm salt soaks for 15 min increments up to 3 times a day. Education was given on taking pressure from nail by placing cotton underneath the nail at the site of injury in order to relieve pressure. This is to be changed frequently. Be sure to choose a sensible choice in footwear and wear open toe sandals whenever possible. Keep the toe clean from debris and excessive bacteria’s. Mother taught proper directions and dosing for OTC pain relievers. I also spoke with the mother regarding the BMI of the patient. I encouraged her to begin increasing his exercise regimen and limiting his time playing video games and any other sedentary habits. She verbalized a desire to begin introducing more healthy foods into his diet and limiting fatty and lower nutritional foods as well. Immunizations given- N/A UTDPreventive care: (List specifics for this age group: Safety counseling, Nutrition)- As I was examining the patients toe, I inquired about his school experience. We talked about the dangers of drugs and stressed the avoidance of taking things from other children such as candy, pills, food, or drinks. He verbalized the understanding and mother agreed. We discussed peer pressure and pt was encouraged to be open and honest with his mother about such situations. Follow-up instructions- Pt mother advised to follow up in 1 week or if the symptoms worsen or do not improve. I advised that there is no improvement within 72 hours, bring pt back for a wound culture. Information was given regarding possible toenail removal in the future. In regards to the Rhinitis, mother was advised to RTC if mucus begins to change in color-especially if yellow or green coloration begins. She was encouraged to begin and OTC allergy medication as the spring season comes in. During this visit, I was able to address several core competencies. The first one being in the scientific foundation topic (2). I was able to integrate my knowledge within the context of nursing to build a relationship with this patient and mother while implementing proper care techniques. I also met a competency under the leadership topic (4) and used improved access, quality and cost effective care for this patient. I was able to treat the patient to the best of my ability while maintaining the patient the most cost effectiveness for him as well. I did not order unnecessary testing and chose a medication that was affordable and effective for his presenting problem. Another competency met was also in the leadership level (6). I communicated my knowledge with the mother verbally and thoroughly explained all treatment and preventative plans. She received proper teaching and care guidelines to result in the best outcome possible. I was then able to meet the writing guideline when completing my SOAP note within the EMR function regarding this encounter ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download