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Proper intervention in a patient's condition depends on a number of issues, which include the relation between doctor and patient, availability of medical facilities, and the skills that the medical specialist possesses. In this regard, the patient's information must be documented and kept safe without encroachment by unauthorized people. Documentation and record-keeping carried out by nurses concerning the patient's clinical condition are very important as they will help in proper evaluation and monitoring of the patient's progress.

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With regard to this, the SOAP nursing framework that includes subjective data, objective data, assessment, and the plan is appropriate in the sense that it facilitates proper documentation of the patient's information basing on his/her condition for easier supervision and medical intervention.

Using this framework, the attending doctor and nurse are able to give their impressions of the patient (Robinson & Ava, 2015). Moreover, the physician is able to report the behaviors and conducts of the patient as a result of their interaction. Medical specialists will also be in a position to define the performance of the patient as a result of the interaction with him/her and they will finally prescribe the type of treatment plan that is appropriate for the patient with regard to the kind of information collected as a result of the doctor's examination and socialization process (Goldman, 2011). Therefore, this essay focuses on SOAP analysis concerning the case of Mr. L. S.

My SOAP nursing documentation for the patient will be as follows:

S (Subjective Data)

Chief Complaint: Mr. L. S.

History of Present Illness

Location: Stomach.

Quality: Low.

Severity: High.

Duration: 5 days.

Timing: Severe chest pain during day time.

Context: Body weakness.

Relieving Factors: Pain relievers.

Exacerbating Factors: Smoking.

Associated Symptoms: Fever, nausea, headache, and dizziness among others.

Review of Systems

Constitutional: Weight loss, severe chest pain, chilling at times, and general body weakness.

Head: Light hair on the head.

Face: Brownish.

Eyes: Blurred vision (cannot see properly).

Ears: No sign of hearing loss.

Nose: Neither sneezing nor running nose.

Mouth/Throat/Neck: Sore throat.

Respiratory: Shortness of breath.

Cardiovascular: Severe chest pain.

Breast: Large.

GI (Gastrointestinal): Not detected.

GU (Genitourinary): Not detected.

Reproductive: Not affected.

Musculoskeletal: Occasional back pain.

Skin/Integument: Small rash is seen.

Psychiatric: No history.

Neurological: Slight headache and dizziness.

Endocrinologic: High body temperature leading to sweating.

Hematologic: No signs of anemia.

Lymphatics: No history.

Allergies: No history.

Diagnostic results: No records.

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Past History (include dates)

PMH: N/A

PSH: N/A

Past Psychiatric Hx: N/A

Obstetrical History: N/A

Hospitalizations: Was hospitalized 5 years ago.

Medications: Dosage: 4 tablets of Nitroglycerin as of 25/02/2011.

Route: 4/2.

Frequency: Twice daily

Allergies: N/A

Dietary Hx: Average.

Immunizations: Fully immunized.

Health Promotion: Newsletters.

Functional Status: : ADLs Functional.

Family History: Alive, deceased, age, diseases, health conditions that place patient at risk (ages).

Grandparents: Deceased at the age of 78 years.

Parents: Deceased at the age of 66 years.

Siblings: 3, one suffering heart problems.

Children: 2, none affected.

Social History

Cultural Background: African American.

Spiritual History/Religious Affiliation and Practices: Protestant.

Activities of Daily Living/Hobbies/Interests: Tennis.

Type of Family: Nuclear.

Marital Status: Married.

Parental Status: A father of 2 children.

Work History: Full time employed.

Financial History: Financially stable.

Sexual History/Orientation: Bi-sexual.

Use of Alcohol, Smoking, or Recreational Drugs: Smokes a pack of cigarettes a day.

Living Arrangements: He lives an average life.

Travel History: Travels a lot.

Social Support: From a community health volunteer.

Level of History

Expanded HPI (1-3 Findings); ROS - 2; PFSH N/A

O (Objective Data)

Physical Exam

Vital Signs: Body weakness.

Oxygen Saturation: 95% (this is slightly below normal range).

Ht: 198cm.

Wt: 95kg.

BMI: 0.479798.

Constitutional: Weight loss, severe chest pain, chilling at times, and general body weakness.

Head: Light hair on the head.

Face: Brownish.

Eyes: Blurred.

Ears: Clear (he hears well).

Nose: Often sneezes.

Mouth/Throat/Neck: Sores detected.

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Respiratory: Suffocating.

Cardiovascular: Narrow veins.

Breast: Large.

GI (Gastrointestinal): N/A

GU (Genitourinary): N/A

Reproductive: Not affected.

Musculoskeletal: Node on the back.

Skin/Integument: Rashes on some parts.

Psychiatric: N/A

Neurological: Lump on the neural vein.

Endocrinologic: Temperature (400C).

Hematologic: N/A

Lymphatics: N/A

Allergies: No allergic reactions.

Diagnostic Results: The patient may be suffering from cholecystectomy.

Determine Billing Level of Physical Objective Examination:

Expanded: problem-focused (2-4 body parts or organ system (6-11 elements). This can help determine the specific problem that the patient is suffering from to be able to come up with comprehensive medical intervention using the laboratory data below.

Mouth/Throat/Neck: Sores detected.

Respiratory system: Suffocating.

Cardiovascular: Narrow veins.

Breast: Large.

Musculoskeletal: Node on the back.

Skin/Integument: Rashes on some parts.

A (Assessment)

Main Diagnosis

Based on my assessment of the patient, the diagnosis from the history and physical exam is given below.

i. Cholecystectomy.

Additional Health Problem/Dx

i. Alpha-1-antitrypsin deficiency.

The clinical findings above, which are based on the assessment, show that the patient might be resistant to certain medical practices that are prescribed to him with an aim of ensuring his enhanced welfare.

Differential Diagnoses

The probability of the patient suffering from cholecystectomy is higher than the chances of Alpha-1-antitrypsin deficiency. Cholecystectomy is a surgical operation that involves the removal of the gallbladder. It is mainly done in human beings in cases when gallbladder diseases cause severe complications and problems that may demand its removal. Gallstones have always been the main reason why this type of procedure should be carried out in the sense that they cause pain that is intolerable by people.

The gallbladder is a very vital organ in the body of human beings as it stores bile which is produced by the liver. Bile plays an important role when it comes to the digestion process, especially breaking down fats into simple substances that can easily be absorbed in the bloodstream without any problem.

Risk Factors

  1. Digestion failure

The failure of digestion of fats may lead to serious problems in the body of an individual.

  1. Surgery consequences

Laparoscopy is a type of surgical operation in human beings that involves small incisions in the body as opposed to the normal open surgery that is very painful and takes a long period of time to heal (Marks, 2013). This kind of operation is less painful and takes a short period of time to close. Any surgical operation involves blood loss as patients bleed and, as a result of this, blood transfusion is mandatory to facilitate life during the surgical procedure and afterward for normal functioning of the body.

  1. Blood transfusion problems

The patient may require blood transfusion as there will be loss of blood as a result of the surgical procedure he will probably be subjected to (Goldman, 2011).

P (Plan)

On arrival at the hospital, the patient was physically examined and tested to diagnose his condition and be able to plan for intervention.

Diagnostics

the following are additional laboratory tests necessary for the patient:

  1. Electrocardiogram (ECG);
  2. Chest X-ray;
  3. Blood tests.

Pharmacologic Management (Rx)

  1. Nitroglycerin;
  2. Over-the-Counter Antacids.

Non-Pharmacologic Management

  1. Hot packs;
  2. Position changes.

Complementary Therapies

  1. Physical exercises;
  2. Diet control.

Education

The patient has to be educated about his disease in terms of the possible causes, signs to watch, treatment plan, and the process of education would include:

  • pamphlets;
  • medical newsletters;
  • medical journals;
  • trained nurses;
  • trained volunteer community workers (Goodlin, 2009).

Referrals: N/A

Follow up/Appointment: the patient should return to the clinic after two weeks for a follow-up checking and if this is not possible, then the nurse will visit him at home.

Final Level of Decision Making

Moderate Complexity: based on Hx, even though the patient is not psychologically affected, he smokes a pack of cigarettes daily, his cardiovascular veins are narrow, he has a node on the musculoskeletal back, and has rashes on some parts of the body, meaning that his current and anticipated future condition would be complex to manage.

Billing Level

Patient Status: Level II.

Level of History: Level III.

Level of Physical Exam: Level II.

Level of Medical Decision Making: Level I.

Subjective and Objective Data

Looking at the subjective and objective data, Mr. L. S. has got the following characteristics:

  1. Bp = 139/94, Wt = 60kg, T = 36.4c, pH6, P = 105, Ht = 198cm.
  2. He is very resistant to drugs, but he has to take them due to the need for surgery to correct his worsening medical condition.
  3. Mr. L. S. should agree with the idea of blood transfusion.
  4. Proper treatment should be given to him basing on his attitude and clinical condition (Ball, Dains, Flynn, Solomon, & Stewart, 2015).
  5. There should be proper communication delivered to him.
  6. As Ball et al., (2015) noted, the patient's background, problem, and the doctor's/nurse's recommendations contribute to the success of treatment.
  7. For instance, Mr. L. S.'s situation includes sore throat, suffocation, narrow cardiovascular veins, large breast, the node on the musculoskeletal back, and rashes on some parts of the skin.
  8. Decisions like the need for laparoscopy as opposed to the normal open operation are done to ensure the well-being of the patient (Ball et al., 2015).
  9. Laparoscopy is selected due to the shorter period of time one needs to heal the operated part as well as reduced pain to be felt during the operation (Spry, 2010).

Plan

In terms of the plan, it is true that appropriate nursing interventions should be implemented so as to deal with certain medical problems that are critical and require special attention. For instance, in the case of any surgical operation, proper preoperational and post-operational care should be enhanced in the sense there is no loss of lives before, during, and after the surgical process. Surgeons should be careful during surgeries to ensure that the welfare of the patient is well catered for without any limitation (Kaewprom, Curtis, & Deane, 2011).

In the case scenario, preoperational care was well-provided and this is one of the nursing interventions that are employed in the case scenario. Preoperational care involves all the interventions that are taken prior, during, and after any surgical operation are done (Spry, 2010).

At the stage before surgery, the patient is thoroughly examined in terms of his or her general health to ensure that the surgical process does not affect him/her negatively in any given circumstances. This involves checking the amount of blood required before one is subjected to surgery, the pressure of one's blood, and many other vital issues are checked upon after which the necessary conditions are created that enable the surgery process to be successful without any loss of lives.

In the case scenario, Mr. L. S. was examined after which a prescription was done that recommended that a blood transfusion would be necessary for him. Intra-operational care is provided during the operation in the sense that the individuals carrying out the operation ensure that the patient does not die during the process. This is always achieved if the surgical guidelines are properly observed without any neglect.

Post operational care is provided after the surgical operation has been finished. This is done to ensure that the patient does not develop other complications after he/she has undergone any operation in his/her body. Surgeons or nurses have to follow and monitor the progress of the patient. Preoperational care is one of the nursing interventions that have been observed in the case scenario where Mr. L. S. is expected to undergo cholecystectomy.

Conclusion

In summary, SOAP analysis is important because it ensures that proper information is documented by the medical experts with regard to any treatment or procedure they may want the patient to undergo as this will help prevent any resistance to medical treatment.

Code: Sample20

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