Using SOAP, write a sample documentation entry for this encounter
What will be an ideal response?
Answer will vary but should include the following elements.
S: 78-year-old woman states she has eaten less meat because of her financial situation and the
trouble of preparing a meal "just for me." Over the past 2 to 3 months she has felt increasingly
tired despite sleeping well at night. Denies dyspnea or palpitations.
O: VS within normal limits (WNL). Alert and oriented. Skin pale, warm, and dry. No murmur,
splenomegaly, or glossitis. Laboratory values: decreased Hct, Hgb, MCV, RDW, Fe, and ferritin
levels. Stool guaiac negative. Currently takes medications for hypertension and arthritis.
A: Iron-deficiency anemia
P: Started on ferrous sulfate (Feosol) 325 mg orally once per day
Teaching provided regarding ferrous sulfate, dietary intake of iron, and managing fatigue
Return for follow-up in 3 months.
You might also like to view...
The nurse instructs a client with chronic renal disease on the prescribed medication furosemide (Lasix). Which client statement indicates that teaching has been effective?
A) "I will take this medication to keep my calcium balance normal." B) "This medication will make sure I have enough red blood cells in my body." C) "I will take this pill to keep my protein level in my body stable." D) "This pill will reduce the swelling in my body and get rid of the extra potassium."
The nurse notes ulcerations on the surfaces of the patient's toes and assesses this as an indication of:
1. skin breakdown from pressure. 2. nutritional deficit. 3. venous stasis. 4. arterial stasis.
Assessing the kidneys for tenderness or pain is done by lightly striking the fist at the __________, which is the area where the lower ribs meet the vertebrae
Fill in the blank(s) with correct word
The nurse has identified a clinical problem as a potential research question. Which of these steps should the nurse take next?
a. Identify the variables b. Formulate the research hypothesis c. Perform a literature review d. Determine financial resources for the research project