Nurse Practitioner SOAP Notes

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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.

SUBJECTIVE DATA:

            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
Duration Three weeks
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

            Breasts:N/A

            Respiratory:No respiratory distress

            Cardiovascular:Regular rhythm for S1 and S2

            Musculoskeletal:Normal

            Psychiatric:N/A

            Neurological:Is alert and well oriented

            Hematologic: Normal

            Endocrine:Normal

OBJECTIVE DATA:

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

Chest/Lungs:Normal

Heart/Peripheral Vascular:Normal and regular rhythm

Abdomen:Soft, tender, and scaly

Genital:N/A

Musculoskeletal:well supported and normal

Neurological:Alert and well oriented

.

ASSESSMENT:

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.

 

Holistic Care

Chronic Condition Status Plan
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

 

PLAN:

Condition Pharmacological Nonpharmacological

Alternative Treatments

Test Follow up

Referral

Rationale
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.

REFLECTION:

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.

References

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.

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