Nursing SOAP Notes

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Practicum: Nursing SOAP Notes (Pediatric Patient aged 0 months to 16 years)

In my practicum experience, I had an opportunity to assess a patient aged five years who suffered from atopic 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. SOAP notes are a method of documentation used by the health care providers to develop a patient’s chart. It is a standard method of providing patient information in the form of admission notes and medical histories. The acronym stands for Subjective, Objective, Assessment, and Plan.

Subjective

The patient was a young boy aged five years who was presented to the health facility during my practicum experience by her mother. On arrival at the facility, the boy was fast to explain his condition. He complained of dry skin, repeated scratching on most parts of the skin that covers the face, scalp, and the limbs. He stated that he felt intense pain around the scratched areas that sometimes developed lesions. Her mother explained that her child had extreme itching and inflamed skin rashes. They caused the sections appear reddish and swell. She also observed small blisters, cracks, and scaling on the skin. She used to apply petroleum jelly on the dry skin sections to no avail and also gave pain relievers to the child to ease the pain from scratching. His nights were sleepless due to the intense scratching and rashes at night. According to the child’s mother, the condition had been persistent for three weeks and seemed to worsen that prompted her to seek for clinical intervention. The details provided by the boy were inconsistent in comparison to that of the mother but indicated the intensity of the condition to him. The discrepancies in the details provided could be due to lack of a proper understanding of what affected the boy.

Objective

I found it appropriate to perform a physical examination to the boy and also seek for additional information from the mother. I inquired of the use of irritants like soap and detergents, previous skin infections, and effect of extreme temperature and humidity conditions. I also inquired about food allergies and inhaled allergens since some children react to particular types of foods and allergen products. The mother explained that she occasionally used irritant soaps on the boy. She also explained that the boy has not had a previous skin infection or dietary allergies.

The physical assessment focused on the condition of the itchy skin regarding the report of scratching and rubbing for the child. I also checked on the history of itchiness in the skin, history of asthma, dry skin, and the punched out erosion that are uniform in appearance.

From the assessment, the child had a history of scratching and rubbing over the previous three weeks and had an itching feeling on the skin. He had no history of asthma, but his skin was dry and with erosion due to scratching.

Assessment

The differential diagnosis for the patient condition was atopic dermatitis, pediatric contact dermatitis, and scabies. Contact dermatitis has various subdivisions and can be due to irritants, allergens, and reactions to pharmacologically active agents. Contact dermatitis can be self-limiting, and morbidity arises from its cause and the possibility of avoiding repeated exposure. The symptoms have similarities to those exhibited by the patient. Scabies appear as grayish, threadlike elevations on the epidermis. The patient may scratch the sections and develop lesions resulting to secondary infection. For atopic dermatitis, the skin has intense itching lesions and the patient has aggressive scratching effect on major parts of the skin. The patient develops skin lesions with varying severity of inflammation (Eichenfield, Tom, et. al., 2014). The likely primary diagnosis for the patient condition was atopic dermatitis due to the association of the symptoms with the condition.

Plan

The plan for diagnostics and primary diagnosis followed a set of procedures. I used the findings of the history and physical examination as well as the responses obtained from the mother. I also assessed the exposure to the irritating substances, allergens, and dietary choices. There was no specific laboratory test to conduct or histologic features to use. Based on the data obtained from the assessment, the patient was likely to suffer from atopic dermatitis that caused the itching and scratching effect. Thus, it was necessary to administer an appropriate management and follow-up plan.

I advised the mother on the factors that provoke atopic dermatitis, how to recognize it, and how to offer support to the child. It was necessary for the child to have short nails and also avoid the use of detergents and soaps that are irritating. Also important was to keep the skin hydrated and reduction of water loss. The recommended medication to control itching and inflammation was corticosteroid cream (Ring, Alomar, et.al. 2012). I also recommended the oral anti-itching drugs in the class of antihistamines. It was necessary to have anti-medication therapies like the use of stress management to the child, behavioral modification, and wet dressing. The mother required maintaining a progressive communication with the child through ought to have the treatment period. The treatment and management plan is appropriate for the condition and also effective in reducing the impact of the infection.

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.

Bibliography

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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