10 Common Registered Nurse SOAP Note Examples

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List of cases

1. Post-Operative Care
2. Wound Care Assessment
3. Diabetes Management
4. Respiratory Assessment
5. Pain Management
6. Cardiac Monitoring
7. Neurological Assessment
8. Gastrointestinal Issues
9. Medication Administration
10. Fall Risk Assessment

1. Post-Operative Care

Description

Patient assessment following total knee replacement surgery, focusing on post-operative recovery, pain management, and early mobilization.

SOAP Note

Patient Name: Margaret Johnson

Date of Visit: 09/01/2024

Subjective

Margaret Johnson, a 65-year-old female, post-operative day 1 following right total knee replacement. Patient reports pain level 6/10 at surgical site, describing it as "throbbing" and worse with movement. States pain medication provides relief, reducing pain to 3/10. Reports mild nausea but no vomiting. Denies chest pain or shortness of breath. Expresses anxiety about first mobilization. Last bowel movement pre-operative day. Voiding without difficulty via bedside commode.

Objective

• Vital Signs:
  • BP: 132/78 mmHg
  • HR: 82 bpm
  • RR: 18/min
  • Temp: 37.2°C
  • SpO2: 96% on room air
• Physical Assessment:
  • Surgical Site:
    • Dressing clean, dry, and intact
    • Minimal serosanguineous drainage noted
    • Mild swelling at surgical site
  • Extremities:
    • Right leg elevated on pillow
    • Peripheral pulses 2+
    • Capillary refill less than 3 seconds
  • Pain Scale: 6/10 at rest, 8/10 with movement
• Medications:
  • PCA Hydromorphone used 4 times in past 8 hours
  • Last oral pain medication 2 hours ago

Assessment

1. Acute post-operative pain related to surgical intervention
2. Risk for impaired mobility related to surgery and pain
3. Risk for post-operative complications (DVT, infection)
4. Anxiety related to mobilization

Plan

1. Pain Management:

   • Continue PCA hydromorphone as ordered
   • Administer oral pain medications per schedule
   • Assess pain q4h and PRN

2. Mobility:

   • Physical therapy evaluation scheduled for afternoon
   • Assist with position changes q2h
   • Encourage ankle pumps and quad sets

3. Monitoring:

   • Assess surgical site q4h
   • Monitor vital signs q4h
   • Neurovascular checks q4h

4. Patient Education:

   • Review pain management techniques
   • Explain importance of early mobilization
   • Demonstrate deep breathing exercises

5. Documentation:

   • Record pain levels and interventions
   • Document mobility progress
   • Note any complications or concerns

2. Wound Care Assessment

Description

Assessment and management of a diabetic foot ulcer requiring regular wound care and monitoring.

SOAP Note

Patient Name: Robert Smith

Date of Visit: 09/02/2024

Subjective

Robert Smith, a 58-year-old male with Type 2 Diabetes, presents for wound care of a right plantar foot ulcer present for 3 weeks. Patient reports minimal pain at wound site (2/10) but describes occasional "burning sensation" around the wound. Denies fever or chills. States he has been following diabetic diet and checking blood glucose regularly. Reports compliance with off-loading instructions and elevated foot positioning at home.

Objective

• Vital Signs:
  • BP: 138/84 mmHg
  • HR: 76 bpm
  • RR: 16/min
  • Temp: 36.8°C
• Wound Assessment:
  • Location: Right plantar surface, base of first metatarsal
  • Size: 2.5cm x 2.0cm x 0.3cm
  • Wound Bed: 80% granulation tissue, 20% slough
  • Exudate: Moderate, serosanguineous
  • Periwound: Slight erythema, intact
  • Odor: None
• Circulation:
  • Pedal pulses: 2+ bilateral
  • Capillary refill: 3 seconds
• Blood Glucose: 156 mg/dL

Assessment

1. Stage 2 diabetic foot ulcer with signs of healing
2. Risk for infection related to diabetes and open wound
3. Adequate peripheral circulation
4. Effective wound care management

Plan

1. Wound Care:

   • Clean wound with normal saline
   • Apply prescribed antimicrobial dressing
   • Secure with roll gauze and cohesive wrap

2. Patient Education:

   • Reinforce proper foot care
   • Review signs of infection
   • Discuss importance of glucose control

3. Monitoring:

   • Weekly wound measurements
   • Assess for signs of infection
   • Monitor glucose levels

4. Referrals:

   • Schedule follow-up with wound care specialist
   • Coordinate with diabetes educator
   • Consider podiatry consultation

5. Documentation:

   • Photo documentation of wound
   • Record wound measurements
   • Note any changes in healing progress

3. Diabetes Management

Description

Assessment and care of a patient with poorly controlled Type 2 Diabetes requiring insulin adjustment and education.

SOAP Note

Patient Name: Linda Martinez

Date of Visit: 09/03/2024

Subjective

Linda Martinez, a 52-year-old female, presents with concerns about elevated blood glucose readings over the past week. Reports morning readings ranging from 200-250 mg/dL and evening readings 180-220 mg/dL. Denies symptoms of hypoglycemia. Reports following prescribed insulin regimen but admits to dietary indiscretions during recent family gatherings. Denies polyuria, polydipsia, or vision changes. States understanding of diet but struggles with portion control.

Objective

• Vital Signs:
  • BP: 142/88 mmHg
  • HR: 78 bpm
  • RR: 16/min
  • Temp: 36.7°C
  • BMI: 31.2 kg/m²
• Physical Assessment:
  • Skin: Warm, dry, intact
  • Extremities:
    • No edema
    • Sensation intact to monofilament testing
    • Pedal pulses 2+ bilateral
• Blood Glucose: 212 mg/dL (random)
• Recent Labs:
  • HbA1c: 8.4% (2 weeks ago)
  • Basic Metabolic Panel: Within normal limits

Assessment

1. Uncontrolled Type 2 Diabetes (elevated HbA1c and blood glucose)
2. Knowledge deficit regarding dietary management
3. Risk for complications related to poor glycemic control
4. Obesity contributing to insulin resistance

Plan

1. Blood Glucose Management:

   • Review blood glucose log
   • Adjust insulin per sliding scale
   • Implement carb counting system

2. Patient Education:

   • Provide meal planning guidance
   • Review proper insulin administration
   • Discuss importance of regular exercise

3. Monitoring:

   • Daily blood glucose checks (QID)
   • Weekly weight monitoring
   • Regular BP checks

4. Lifestyle Modifications:

   • Set realistic dietary goals
   • Create exercise plan
   • Stress management techniques

5. Follow-up:

   • Schedule diabetes education class
   • Weekly nurse follow-up calls
   • Monthly clinic visits

4. Respiratory Assessment

Description

Assessment and management of a patient with COPD exacerbation requiring oxygen therapy and breathing treatments.

SOAP Note

Patient Name: George Wilson

Date of Visit: 09/04/2024

Subjective

George Wilson, a 70-year-old male with COPD, presents with increased shortness of breath over past 24 hours. Reports using rescue inhaler more frequently than usual (6 times in last 24 hours). Describes dyspnea as "worse than usual" with minimal exertion. Notes increased productive cough with yellowish sputum. Denies fever or chest pain. Reports compliance with maintenance inhalers but admits to missing morning dose due to symptoms.

Objective

• Vital Signs:
  • BP: 148/82 mmHg
  • HR: 92 bpm
  • RR: 24/min
  • Temp: 37.1°C
  • SpO2: 89% on room air, 94% on 2L O2
• Respiratory Assessment:
  • Breath Sounds:
    • Diminished bilaterally
    • Expiratory wheezes throughout
    • Prolonged expiration
  • Work of Breathing:
    • Mild accessory muscle use
    • Pursed-lip breathing
    • Sitting in tripod position
• Peak Flow: 180 L/min (Personal best: 250 L/min)

Assessment

1. COPD exacerbation with decreased oxygen saturation
2. Increased work of breathing
3. Risk for respiratory failure
4. Anxiety related to dyspnea

Plan

1. Immediate Interventions:

   • Administer prescribed nebulizer treatment
   • Continue oxygen therapy at 2L/min
   • Position for optimal breathing

2. Medication Management:

   • Review inhaler technique
   • Administer scheduled medications
   • Document response to treatments

3. Monitoring:

   • Continuous SpO2 monitoring
   • Respiratory assessment q2h
   • Peak flow measurements q4h

4. Patient Education:

   • Review COPD action plan
   • Demonstrate proper inhaler use
   • Discuss energy conservation

5. Documentation:

   • Record respiratory status changes
   • Note treatment effectiveness
   • Document patient education

5. Pain Management

Description

Assessment and management of chronic pain in a patient with rheumatoid arthritis experiencing acute flare.

SOAP Note

Patient Name: Patricia Davis

Date of Visit: 09/05/2024

Subjective

Patricia Davis, a 62-year-old female with rheumatoid arthritis, reports increased joint pain over past 3 days. Describes pain as "severe aching" in hands, wrists, and knees, rated 8/10. Morning stiffness lasting 2+ hours. Reports difficulty with ADLs due to pain. States prescribed pain medication provides minimal relief. Denies fever or new swelling. Sleep disturbed due to pain.

Objective

• Vital Signs:
  • BP: 128/76 mmHg
  • HR: 80 bpm
  • RR: 16/min
  • Temp: 36.9°C
• Pain Assessment:
  • Location: Bilateral hands, wrists, knees
  • Quality: Aching, constant
  • Severity: 8/10
  • Aggravating factors: Movement, morning
  • Relieving factors: Heat, rest
• Joint Assessment:
  • Bilateral hand joints: Warm, tender
  • Wrists: Limited ROM, tender
  • Knees: Mild swelling, painful ROM

Assessment

1. Acute on chronic pain related to RA flare
2. Impaired physical mobility
3. Sleep disturbance related to pain
4. Risk for decreased independence in ADLs

Plan

1. Pain Management:

   • Administer prescribed medications
   • Apply heat therapy to affected joints
   • Position for comfort

2. Activity Modifications:

   • Assist with ADLs as needed
   • Implement energy conservation
   • Gentle ROM exercises

3. Monitoring:

   • Pain assessments q4h
   • Monitor medication effectiveness
   • Assess joint changes

4. Patient Education:

   • Review pain management techniques
   • Discuss joint protection
   • Teach relaxation methods

5. Documentation:

   • Record pain levels and interventions
   • Note functional limitations
   • Document education provided

6. Cardiac Monitoring

Description

Assessment and monitoring of a patient admitted with new onset atrial fibrillation requiring rate control.

SOAP Note

Patient Name: William Thompson

Date of Visit: 09/06/2024

Subjective

William Thompson, a 68-year-old male, admitted with new onset atrial fibrillation. Reports feeling "heart racing" and "fluttering" in chest. Denies chest pain but notes mild shortness of breath with activity. Reports dizziness when standing quickly. Taking medications as prescribed. Appetite normal, sleeping adequately with head elevated. Denies ankle swelling.

Objective

• Vital Signs:
  • BP: 138/82 mmHg
  • HR: 110-120 bpm, irregular
  • RR: 18/min
  • Temp: 36.8°C
  • SpO2: 96% on room air
• Cardiac Assessment:
  • Heart Sounds:
    • Irregular rhythm
    • No murmurs or gallops
  • Telemetry:
    • Atrial fibrillation
    • Rate 110-120
    • No ectopy noted
• Other Systems:
  • Lungs clear bilaterally
  • No peripheral edema
  • Capillary refill less than 3 seconds

Assessment

1. Atrial fibrillation with rapid ventricular response
2. Risk for thromboembolism
3. Potential for decreased cardiac output
4. Risk for falls related to new medication regimen

Plan

1. Cardiac Monitoring:

   • Continuous telemetry monitoring
   • Vital signs q4h
   • Daily weight measurements

2. Medication Management:

   • Administer rate control medications
   • Monitor anticoagulation therapy
   • Track medication effectiveness

3. Activity:

   • Assist with ambulation
   • Monitor for orthostatic changes
   • Implement fall precautions

4. Patient Education:

   • Explain atrial fibrillation
   • Review medication purposes
   • Discuss lifestyle modifications

5. Documentation:

   • Record rhythm changes
   • Note response to medications
   • Document patient education

7. Neurological Assessment

Description

Assessment and monitoring of a patient following a transient ischemic attack (TIA).

SOAP Note

Patient Name: Helen Anderson

Date of Visit: 09/07/2024

Subjective

Helen Anderson, a 72-year-old female, admitted following TIA with left-sided weakness. Reports resolution of symptoms but notes residual "clumsiness" in left hand. Denies headache, vision changes, or speech difficulties. States feeling anxious about possibility of future events. Reports compliance with medications. Denies falls or dizziness.

Objective

• Vital Signs:
  • BP: 142/84 mmHg
  • HR: 76 bpm, regular
  • RR: 16/min
  • Temp: 36.9°C
  • SpO2: 97% on room air
• Neurological Assessment:
  • LOC: Alert and oriented x3
  • Pupils: PERRLA, 3mm
  • Cranial Nerves: Intact
  • Motor: 5/5 strength bilaterally
  • Sensation: Intact to light touch
  • Coordination: Slight left hand dysmetria
  • Gait: Steady with minimal assistance

Assessment

1. Post-TIA status with mild residual symptoms
2. Risk for future cerebrovascular events
3. Anxiety related to health status
4. Fall risk related to mild coordination deficit

Plan

1. Neurological Monitoring:

   • Neuro checks q4h
   • Monitor for new symptoms
   • Assess coordination changes

2. Safety Measures:

   • Fall risk precautions
   • Assist with ambulation
   • Environmental safety check

3. Patient Education:

   • Review stroke warning signs
   • Discuss risk factor modification
   • Explain medication purposes

4. Activity:

   • Progressive mobility plan
   • OT/PT evaluation
   • Safety with ADLs

5. Documentation:

   • Record neurological status
   • Note functional improvements
   • Document education provided

8. Gastrointestinal Issues

Description

Assessment and management of a patient with acute gastroenteritis requiring fluid and electrolyte monitoring.

SOAP Note

Patient Name: Carlos Rodriguez

Date of Visit: 09/08/2024

Subjective

Carlos Rodriguez, a 45-year-old male, presents with 24-hour history of nausea, vomiting, and diarrhea. Reports 6 episodes of vomiting and 8 loose stools in past 24 hours. Describes "crampy" abdominal pain, rated 5/10. Reports decreased oral intake and dark urine. Denies fever or bloody stools. States feeling weak and dizzy when standing.

Objective

• Vital Signs:
  • BP: 110/70 mmHg
  • HR: 98 bpm
  • RR: 18/min
  • Temp: 37.3°C
  • Orthostatic BP: -12 systolic with position change
• Physical Assessment:
  • Skin: Warm, dry, decreased turgor
  • Abdomen:
    • Soft, diffusely tender
    • Active bowel sounds
    • No rebound tenderness
  • Mucous Membranes: Dry
• Labs:
  • Na+: 138 mEq/L
  • K+: 3.4 mEq/L
  • Cl-: 98 mEq/L

Assessment

1. Acute gastroenteritis with moderate dehydration
2. Electrolyte imbalance risk
3. Acute abdominal pain
4. Risk for fluid volume deficit

Plan

1. Fluid Management:

   • Initiate IV fluid therapy
   • Monitor intake and output
   • Track fluid balance

2. Symptom Management:

   • Administer antiemetics
   • Provide comfort measures
   • Monitor bowel movements

3. Monitoring:

   • Vital signs q4h
   • Assess hydration status
   • Check electrolytes

4. Patient Education:

   • Explain fluid replacement
   • Discuss dietary progression
   • Review hand hygiene

5. Documentation:

   • Record I&O
   • Note symptom changes
   • Document response to treatment

9. Medication Administration

Description

Assessment and monitoring of a patient starting new anticoagulation therapy following deep vein thrombosis (DVT).

SOAP Note

Patient Name: Susan Miller

Date of Visit: 09/09/2024

Subjective

Susan Miller, a 55-year-old female, diagnosed with left leg DVT, starting warfarin therapy. Reports understanding medication teaching but expresses anxiety about bleeding risks. Notes mild left leg pain and swelling. Denies chest pain or shortness of breath. Reports good appetite and normal bowel habits. States commitment to medication compliance and follow-up.

Objective

• Vital Signs:
  • BP: 128/76 mmHg
  • HR: 82 bpm
  • RR: 16/min
  • Temp: 36.8°C
• Assessment:
  • Left Leg:
    • Mild edema
    • Calf tenderness
    • Positive Homan's sign
  • Skin: No bruising or bleeding
• Labs:
  • INR: 1.2
  • PT: 14 seconds
  • Hgb: 13.2 g/dL

Assessment

1. DVT requiring anticoagulation therapy
2. Risk for bleeding related to anticoagulation
3. Anxiety related to new medication regimen
4. Knowledge deficit regarding medication management

Plan

1. Medication Administration:

   • Initiate warfarin per protocol
   • Monitor INR daily
   • Assess for bleeding signs

2. Patient Education:

   • Review medication schedule
   • Discuss diet restrictions
   • Explain monitoring needs

3. Monitoring:

   • Daily INR checks
   • Assess for bleeding
   • Monitor leg symptoms

4. Safety Measures:

   • Fall precautions
   • Bleeding precautions
   • Activity modifications

5. Documentation:

   • Record medication administration
   • Note INR results
   • Document patient education

10. Fall Risk Assessment

Description

Comprehensive fall risk assessment and prevention planning for an elderly patient with recent falls.

SOAP Note

Patient Name: Dorothy White

Date of Visit: 09/10/2024

Subjective

Dorothy White, an 82-year-old female, presents for fall risk assessment following two falls in past month. Reports falls occurred while getting up from chair and in bathroom at night. Denies injury from falls but expresses fear of falling again. Notes increasing difficulty with balance. Currently using walker but admits inconsistent use. Reports taking sleep medication at night.

Objective

• Vital Signs:
  • BP: 134/78 mmHg
  • HR: 76 bpm
  • RR: 16/min
  • Temp: 36.7°C
  • Orthostatic BP: -8 systolic with position change
• Fall Risk Assessment:
  • Mobility: Unsteady gait
  • Balance: Poor
  • Strength: 4/5 lower extremities
  • Vision: Wears bifocals
  • Environment: Throw rugs at home
• Morse Fall Scale: Score 65 (High Risk)

Assessment

1. High fall risk related to multiple factors
2. Impaired physical mobility
3. Fear of falling affecting activity level
4. Environmental safety concerns

Plan

1. Safety Measures:

   • Implement fall precautions
   • Bed in low position
   • Clear path to bathroom
   • Non-slip footwear

2. Patient Education:

   • Safe transfer techniques
   • Proper walker use
   • Home safety modifications

3. Referrals:

   • Physical therapy evaluation
   • Home safety assessment
   • Medication review

4. Monitoring:

   • Regular fall risk reassessment
   • Monitor activity level
   • Track any near-falls

5. Documentation:

   • Record fall risk score
   • Note safety measures implemented
   • Document patient education