Nurse Practitioner SOAP Notes
In my practicum experience, I had an opportunity to assess a patient aged five years who suffered from a topic dermatitis. As required in the nursing practice, I compiled a SOAP note that captured the details of the patient as well as diagnosis and follow-up plan.
Chief Complaint (CC): Dry skin and repeated scratching due to atopic dermatitis
History of Present Illness (HPI):
|Onset||Three weeks prior to the hospital visit|
|Location||Skin that covers the face, scalp, and limbs|
|Characteristics||dry skin, repeated scratching on most parts of the skin; intense pain around the scratched areas that sometimes developed lesions, small blisters, cracks, and scaling on the skin|
|Aggravating Factors||Use of irritant soap, of extreme temperature and humidity conditions|
|Relieving Factors||Scratching on the skin surface|
|Treatments/Therapies||oral anti-itching drugs in the class of antihistamines|
Medications: Pain relievers, appliedpetroleum jelly
Allergies: No previous allergies
Past Medical History (PMH:No incidence of medical use for the condition
Past Surgical History (PSH): N/A
OB/GYN History: (if applicable) N/A
Personal/Social History: Is a young boy aged five years and liked socializing with others prior to the onset of the condition.
Immunizations:None for the condition
Family History:Negative for atopic dermatitis
Review of Systems:
General:Temperature 36 degrees
Skin: dry, itching, lesions, rashes, cracks, and scaling
HEENT:Normal head, eyes, ears, Throat, and Neck
Neck:Normal and symmetrical
Respiratory:No respiratory distress
Cardiovascular:Regular rhythm for S1 and S2
Neurological:Is alert and well oriented
Vital Signs:HR 80RR15 Temperature 36 degrees BMI14.12
(Pediatric) BP % 86
General: Nourished, in active, and stressed
SKIN:dry, itching, lesions, rashes, cracks, and scaling
HEENT:Normal for all
Neck:Symmetrical and rigid
Heart/Peripheral Vascular:Normal and regular rhythm
Abdomen:Soft, tender, and scaly
Musculoskeletal:well supported and normal
Neurological:Alert and well oriented
|Diagnosis||Positives||Negatives||Rationale & Reference|
|Atopic dermatitis||Positive for the boy||Intense itching lesions and the boy has aggressive scratching effect on major parts of the skin. The patient developed skin lesions with varying severity of inflammation|
|Pediatric contact dermatitis||Negative for the boy||Similar symptoms to those of scratching and dry skin, but not as intense as exhibited by the boy|
|Scabies||Negative for the boy||Grayish, threadlike elevations on the epidermis. The patient may scratch the sections and develop lesions resulting to secondary infection. They symptoms were not evident for the patient condition|
|Lab/Imaging (Results)||Patient results||Rationale|
|Through patient physical assessment and patient history||History of scratching and rubbing, lesions, itching feeling on the skin, No history of asthma, skin was dry and with erosions||High likelihood of having atopic dermatitis due to the positive results for itching, lesions, and dry skin.|
|Atopic dermatitis||Under treatment||Use of medication- oral anti-itching drugs|
|Lab/Imaging (Results)||Patient results||Rationale|
|patient physical assessment and patient history||scratching and rubbing, lesions, itching feeling on the skin, No history of asthma, skin was dry and with erosions||The method is effective in diagnosis of atopic dermatitis|
|Atopic dermatitis||oral anti-itching drugs (corticosteroid cream as advised by the pharmacist)||Advised the child to maintain short nails and avoid the use of irritating detergents and soaps
Important to keep the skin hydrated and reduce the water loss
Stress management, behavioral modification, and wet dressing
|No specific laboratory test-focused on physical assessment and patient history||Scheduled a follow up visit to the hospital after two weeks to assess the progress||The plan is appropriate for the condition and also effective in reducing the impact of the infection.
Health Promotion: Necessary to educate the parents and the community on the causative factors to atopic dermatitis
Disease Prevention:Important to check for defects on skin barrier function that makes the skin more susceptible to soap, weather, and temperature triggers.
The practicum experience with the patient and her mother was essential in enhancing my skills in nursing practice with pediatrics. I acquired important skills in patient examination and diagnosis. I was amazed by the character of the boy describing how he felt about the disease. Many children fear to share information with care providers. I observed that the disease affected the rate of growth and development of the child. For a similar patient evaluation, I would handle the diagnostic criteria differently by assessing the patient condition for three days before discharge. It would be appropriate to check the difference like the rashes upon presentation and discharge to ascertain of the effectiveness of the management plan.
Burns, C. E., Dunn, A. M., Brady, M. A., Starr, N. B., & Blosser, C. G. (2013) Pediatric primary care (5th ed.). Philadelphia, PA: Elsevier.
Eichenfield, L. F., Tom, W. L., Berger, T. G., Krol, A., Paller, A. S., Schwarzenberger, K., … & Cordoro, K. M. (2014). Guidelines of care for the management of atopic dermatitis: Section 2. Management and treatment of atopic dermatitis with topical therapies: Journal of the American Academy of Dermatology, 71(1), 116-132.
Ring, J., Alomar, A., Bieber, T., Deleuran, M., Fink‐Wagner, A., Gelmetti, C., … & Schäfer, T. (2012). Guidelines for treatment of atopic eczema (atopic dermatitis) part I. Journal of the European Academy of Dermatology and Venereology, 26(8), 1045-1060.
Silverberg JI, Simpson EL. (2013) Association between severe eczema in children and multiple comorbid conditions and increased healthcare utilization. Pediatr Allergy Immunol; 24(5):476-86.