Physcial assessment and soap note 1

Family and Sexual Violence
August 18, 2022
Wind Shield Survey
August 18, 2022

Physcial assessment and soap note 1

Running head: Physcial assessment and soap note 1

Physcial assessment and soap note 8

Physical Assessment and SOAP Note
NSG330 Health Assessment & Diagnostic Reasoning

Stratford University

Physical Assessment and SOAP Note

Patient name: M.S. DOB: 01/08/1984, Asian, Single. 36 years old female

Physical Examination


Height: 5 ft, 7 in (170.18 cm)

Weight: 170 lbs (77.27 kg)

Waist Circumference: 36 inches

BMI: 26.6

Vital Signs: BP-150/90, HR-54 bpm, RR-10/min, Temp-97.9 F

General Survey: Patient features appropriate for her age and ethnicity. She is 36 years old, not under any substance influences currently. Last cocaine use was 2 weeks ago. She went to ED for chest pain and SOB on 2/15/2020. She states that the chest pain and SOB has gotten better in a last few days. BP, HR, and RR elevated. She complaints of SOB and chest pain comes and go. SOB is better with resting and worsen with physical activities. She is making an attempt to minimize her smoking and cocaine use. She is currently living alone in Woodbridge, VA.

Head-To-Toe Examination

Skin: Color appropriate for the ethnicity, moist, and warm. No Swelling, bruises, lesions, mole on the right cheek. No changes on mole. Patient states no changes on her skin.

Hair: Appropriate for her ethnicity, black long, clean, and normal distribution. No lice or dandruff.

Nails: Normal color. She bites her nail.

Nail bed: Clean, nice and firm, capillary refills 5-6 seconds.

Head: No bumps and lumps, non-tender, no dandruffs, or no lice. Examined hair, good hygiene, no odor, no signs of alopecia, appropriate color for her ethnicity.

Face: Symmetrical eyebrows, eyes, no drooling or abnormal movements.

Eyes: Symmetrical, PERRLA-Pupil equal round and reacted to light and accommodation. Pupils constricted 2mm. No signs of jaundice, no drainage, white sclera, eye lid withing normal limit. Vision acuity by Snellen chart: Right and Left 20/20, doesn’t wear contacts.

Background of eyes have even color, no hemorrhage or hematoma. Vessels present in all quadrants without crossing defects.

Ear: Symmetrical, no abnormal drainage, patent, no build up waxes. Tympanic membrane is gray. Whispered voice and normal voice; hearing is good bilaterally.

Nose: No deviated septum, no drainage, not bleeding, no lesions. No signs of sinus problem, no pain during sinus exam. Non-tender, nice and clean inner nose. Patient passes smell test that she can smell things properly. Tested with vanilla flavor and was able to recognize the flavor.

Mouth: Teeth intact, pink mucosa, pink tongue, no lesions or sores in the mouth, gag reflux is present, both tonsils are present. All 4 wisdom teeth were removed at age 17. Gums are pink and looks healthy, no bleeding.

Neck: Straight neck line, able to turn head right and left without difficulty. Free range of motion. Symmetrical, non-tender, no mass, lesions, rash. Small keloid present underneath the chin and PCP recommend to start steroid treatment. No pain on lymph nodes. Midline Trachea. Palpated thyroid, no edema or pain during exam. Palpated carotid arteries simultaneously, weak pulses 1+.

Spine and Back: No signs of scoliosis, no abnormal findings. No pain reported.

Thorax and Lungs: Symmetrical chest expansion, light crackles and wheezing sound is present. Mucus present during cough. No other adventitious sounds.

Breasts: Symmetrical. No dimple, no discharge rashes, no lesions. No mases or lumps. Firm and round. Performs monthly breast exams.

Heart: S1 and S2 are WNL. No heart murmur, listened to apical pulse and matched with radial pulse, weak pulses 1+.

Abdomen: Contour checked, inspection, auscultation, percussion, and palpate all 4 quads, active bowel sounds, last BM yesterday morning. Mild tenderness during palpation.

Extremities: ROM present on both upper and lower. Good strength. Color appropriate to patient’s ethnicity. No edema, no lesions, rashes, bruises, and symmetrical. Diminished peripheral pulses 1+. Presence of pedal edema. Symmetrical upper and lower extremities. No changes stated on all extremities by patient. Slow cap refills on toes, more than 3 seconds, took about 5 seconds. Cool and clammy skin.

Musculoskeletal: Temporomandibular-within normal limit, Neck: slight pain turning to the right. Vertebral column: back pain for last couple of days stated by patient, slight curvature. Arms: symmetric with each other, bruise on the right forearm, complains of both hands’ carpel tunnel syndrome. Legs: symmetrical with each other, slight edema on the both feet (non-pitting). Diminished peripheral pulses. Muscle strength: Complains of pain on hands caused by carpel tunnel syndrome, slight difficulty on maintaining flexion and extension.

Neurologic: Mental status: Alert and oriented x3 (place, person, date), understanding and comprehending everything that is being asked, clear speech, good hearing, dressed appropriately for the weather, LOC-alert and awake, avoiding eye contact. Good memories-was able to tell me why she came to the hospital, Intact cranial nerves II and III. Sensory: able to recognize the touch made with my finger and pen on her face and arms. Stereognosis: recognized the touch made by a cellphone. Motor: moved the patient from the exam table to the chair, assessed risk for fall, slight weakness on walking due to edema. Gait: slightly imbalance but tries to balance it. Romberg test is performed and unable to stand properly when eyes are closed. Cerebellar sign: imbalanced gait; however, she was able to follow the instruction to touch mouth, ear, and eyes. DTRs: Present on upper and lower extremities +2.

Genitalia: External genitalia: small rash on the right side-following up with gynecologist

next week, no open sores or cuts. Internal genitalia: appropriate color of vaginal wall, no signs of infection, no discharge, no bumps or lumps, cervical-nullipara os, no discharge, within normal limit. Upto date for papsmear-12/20/2019-within normal limit, never been sexually active. LMP-12/28/2019. Age of menarch:13 duration:4 days frequency:28 days.

Bimanual examination: slight tender on the right pelvic area, will order for pelvic ultrasound for further evaluation, mudline uterus, no masses or pain. Anus: complains of constipation, emall external hemorrhoid-encouraged to intake adequate fluid and fiber, no abnormal mass, lesions or fissures. Rectal wall: Intact and patent, brown and soft stool-no blood found on hemoccult test.


Cocaine dependent and smokes cigarettes heavily (almost 2 packs a day)

Nicotine dependence

History of uncontrolled HTN, recently diagnosed with CHF and dilated cardiomyopathy

Substance and nicotine abuse

Recently seen for SOB and chest pain at ED

Slightly over-weight by 6-7 lbs

Dental-Full sets of teeth, all wisdom teeth were removed at age 17

Need to educate about using cocaine and nicotine and recommended quit program/rehab

Lonely, doesn’t have lots of friends and doesn’t get along with family

Family lives in NY

Doesn’t show interest on quitting cocaine and cigarettes smoking

Ineffective coping mechanism

Nursing Diagnosis:

1. Decreased cardiac output related to altered in heart rate and rhythm, bloop pressure, and respirations evidenced by chest pain, SOB, and weak peripheral pulses 1+. (Ackley et al, 2017)

Plan: Patient will demonstrate adequate cardiac output as evidenced by blood pressure, pule rate, respiration rate and rhythm within normal parameters for herself; strong peripheral pulses; minimized edema; maintained level of mentation; lack of chest discomfort or dyspnea, syncope, or chest pain before getting discharge. (Ackley et al, 2017)

Plan: Patient will remain free of side effects from the medication used to achieve adequate cardiac output during hospital stay and while under treatment. (Ackley et al, 2017)

Plan: Patient will explain actions and precautions to prevent primary and secondary cardiac disease; therefore, she will take part in the programs to quit smoking and cocaine during the hospital stay. Information provided. (Ackley et al, 2017)

Intervention 1: Recognize primary characteristics of decreased cardiac output as fatigue, dyspnea, edema, orthopnea, paroxysmal nocturnal dyspnea, and increased CVP. Recognize secondary characteristics of decreased cardiac output as weight gain, hepatomegaly, jugular venous distention, lungs crackles, oliguria, coughing, clammy skin, and skin color changes. EBN: A nursing study to validate characteristics of the nursing diagnosis decreased cardiac out in a clinical environment identified and categorized related to client characteristics that were present as primary or secondary (Martins et al, 2010)

Intervention 2: Check blood pressure, pulse, and condition before administering cardiac medications such as angiotensin-converting enzyme inhibitor, angiotensin receptors blockers, digoxin, and beta blockers. Notify health care provider if heart or blood pressure is low before holding medications. It is important that the nurse evaluates how well the client is tolerating current medications before administering cardiac medications; do not hold medications without health care provider input. The health care provider may decide to have medications administered even though blood pressure or pulse rate has lowered. (Ackley et al, 2017)

Intervention 3: Monitor orthostatic blood pressure and daily weight. EB: This intervention assesses for fluid volume status (Yancy et al, 2013).

2. Ineffective coping related to inadequate resources and insufficient social and personal support evidenced by cocaine usage, heavy smoking, lives alone, not having friends and not getting along with family and family lives in NY. (Ackley et al, 2017)

Plan: Patient will identify feelings of isolation by the end of our therapeutic communication. (Ackley et al, 2017)

Plan: Patient will participate in activities and programs at level and desire once she is discharged. (Ackley et al, 2017)

Plan: Patient is encouraged to use the therapeutic groups to minimize the loneliness and stress; therefore, she will use effective behaviors to decrease loneliness and stress attending group or community therapy this weekend. Group and community therapy information provided to patient. (Ackley et al, 2017)

Intervention 1: Establish a therapeutic relationship with the client. EBN: In her study, Skingley (2013) suggests that many of the circumstances that contribute to social isolation and amendable that the community nurse in the position to affect changes by using one-on-one interventions, by involving the client in group activities, and by community engagement. EBN: Nurses are one of the fundamental client advocate groups that promote the prevention of social isolation (Wilson et al, 2011). (Ackley et al, 2017)

Intervention 2: Use verbal and nonverbal therapeutic communication approaches including empathy, active listening, and confrontation to encourage the client to express emotions such as sadness, guilt, and anger (within appropriate limits); verbalize fears and concerns; and set goals. EBN: Ruddick (2011) describes solution-focused communications as enhancing the identification of strength and resources of coping. (Ackley et al, 2017)

Intervention 3: Assist the client to set realistic goals and identify personal skills and knowledge. EB: In a qualitative study, adults (N=9) who were able to lose 10% of body weight and maintain the loss for a minimum of 12 months differed from those (N=9) who were not successful at weight maintenance on factors such as realistic goal setting, self-monitoring, and other effective coping skills (Mckee et al, 2013). (Ackley et al, 2017)


Subjective: Patient is 36 years old female holding on her chest and complaining of chest pain 9 out 10 and SOB stating “It really hurts and having trouble breathing”. She states that chest feels heavy and having constant pain.

Observation: She states “I am having chest pain and can’t breathe,” V/S: BP-150/90, HR-54 bpm, RR-10/min, Temp-97.9 F, cool and clammy skin. Peripheral pulses are weak 1+. Presence of pedal edema and non-pitting. Slow cap refills.

Assessment: Decreased cardiac output related to alteration in heart rate and rhythm evidenced by chest pain and SOB.

Plan: Refer to physician for orders. Client goal-The client will demonstrate adequate output as evidence by heart rhythm within normal parameters or decrease of chest pain or relief from SOB after administering the medication as ordered.

Implementation: Called the doctor to notify the client’s status and request an order for nitroglycerine, administer it, and oxygen at 5 liters/minute via nasal cannula and ask for cardiac enzymes’ labs.

Evaluation: After 5 minutes, the client states the chest pain at 5/10 and decreasing and vital signs of heart rate 92 irregular rhythm, blood pressure 140/86, resp rate 16, oxygen saturation 96% on 5 liters oxygen via nasal cannula, skin is warm and dry, and states “I feel better.”


Jarvis, C., Eckhardt, A. (2020). Physical Examination and Health Assessment (8th Edition). Bloomington, Illinois.

Mackey, M.B., Ackley, B.J. (2017). Nursing Diagnosis Handbook. An Evidence-Based Guide to Planning Care. St. Louis, Missouri, USA: Elsevier.