AGACNP ICU SOAP Note EXAMPLE

AGAC Student

MM/DD/YY

NURS XX Week 7 SOAP Note

Level of Care: ICU

Hospital Day: 2

Specialty: Intensivist

Demographic Data : S.J. 42 year old Black female

SUBJECTIVE
Chief Complaint (CC): Nods head when asked if experiencing abd pain – Unable to

verbalize/Intubated

History of Present Illness (HPI) : Reviewing the chart, patient presented yesterday from home

to ER with 1 day of severe, sharp, constant pelvic abd pain after 4 days of nausea, vomiting and

diarrhea. Denied fever or chills. Reported stool was loose, brown, and watery with no foul smell.

Abd pain was in the lower pelvis, worse with walking or urination, better with lying down. Not

improved with OTC ibuprofen. Denied urinary symptoms of pain, frequency or blood in urine.

Denied vaginal symptoms or discharge. When asked today if pain is better – patient shakes her

head “No”. Nods her head “Yes” that the morphine does improve symptoms.

Current Home Medications Only: Ibuprofen OTC

Allergies: NKDA

Past Medical History: Denies

Past Surgical History: C-section 5 years ago

Social History: Patient lives at home with her spouse. He is supportive. She works full time as a

bank manager. Unable to obtain further data at this time due to inability to verbalize.

Family History: On the chart – lists mother alive at 72 in excellent health, and father alive at 70

with HTN.

Immunization History: Unable to obtain.

Preventative Health History: Unable to obtain

REVIEW OF SYSTEMS – Unable to obtain due to patient intubated.

General: Eyes: Ears, nose, mouth &

throat: Cardiovascular: Respiratory: Gastrointestinal: Skin & Breasts:

Musculoskeletal: Allergic: Immunologic: Endocrine: Hematopoietic/Lymphatic:

Genitourinary: Neurological: Psychiatric/Mental Status:

OBJECTIVE
Vital Signs: 90/55, HR 125 Normal Sinus Tach, RR 26, FiO2 30% on AC Vent PS 5 PEEP5,

VT 500 – SpO2 93%

Laboratory Values: WBC 23.4K, Hgb 8.2, Hct 24.5, Plt 70K; Glu 70, BUN 20, Cr 1.9, K 3.0,

Na 135. Lactate 4.8, ABG: pH 7.35, PaO2 85%, PCO2 30

Radiology Results: CT scan abd/pelvis with IV contrast – ruptured appendicitis with abscess.

CXR – no PNA, no pleural effusion, ETT in good position, Central line good position.

I&O values: UO 20cc/hr, total 500cc/24 hours, IVF 5000 in 24 hours. No BM.

Focused Inpatient Medications: Zosyn 3.375gm IV Q6H, Pepcid 20mg IV Q12H, Heparin

5000U SQ Q8H, Propofol per protocol. Morphine 4 mg IV Q2H PRN Pain. Levophed gtt at 5

mcg/min. D5 ½ with 20mEq Kcl @ 125cc/hr.

Nurse/Consultant Note Review: Patient was intubated yesterday when her sepsis progressed to

significant hypotension, severe metabolic acidosis, and she developed ALOC with concern to

maintain own airway. General Surgery Consult – Ruptured appendicitis, plan for IR drainage,

non-op management unless overwhelming sepsis or acute abd. IR Consult – Plan for IR drainage

pelvic abscess today. Per RN/RT – patient tolerating weaning trial, ABG normalizing, improved

BP, weaning pressors.

PHYSICAL EXAM

General: Well developed, well nourished female, appropriate to stated age. ETT/Vent. Left

subclavian central line.

Eyes: EOM intact. Excellent eye contact. Atraumatic eyelids/sclera. PERRLA

Ears, nose, mouth & throat: Ears/nose/mouth – grossly intact. Oral mucosa moist. Throat –

deferred due to intubation.

Cardiovascular: NST on tele. Heart S1S2, RRR, no murmurs, no rubs. No peripheral edema.

Bilateral radial/dorsalis pedis +3 pulses. Warm, dry extremities. Cap Refill brisk

Respiratory: Lungs clear bilaterally. Chest expansion bilaterally.

Gastrointestinal: Abd soft, distended, tenderness to palpation and guarding over pelvis/RLQ.

Non-tender upper quadrants. Hypoactive bowel sounds.

Skin & Breasts: Skin grossly intact/pink warm. Breasts deferred.

Musculoskeletal: Grossly moves all extremities spontaneously in bed. Purposefully uses arms

to adjust gown. Follows commands.

Allergic: Deferred

Immunologic: Deferred

Endocrine: Deferred

Hematopoietic/Lymphatic: No lymphadenopathy of cervical, clavicular chains. No inguinal

lymphadenopathy. No bruising noted.

Genitourinary: Foley – amber urine

Neurological: Alert. Nods head appropriately. Will evaluate CN 2-12 after extubation. Equal

grips 5/5, equal dorsiflex/plantarflex 5/5.

Psychiatric/Mental Status: Appropriate. No noted distress.

ASSESSMENT
Differential Diagnosis (DDx):

While the patient is experiencing Sepsis, AKI, and Respiratory failure – this is a Problem

Focused SOAP note – and I will focus on the Abdominal differentials/final diagnoses as the

abdomen is the source of the Sepsis, AKI, and Respiratory Failure.

Perforated colonic diverticulitis ICD 10 K57.20

Colonic diverticulosis is an outpouching of the colon wall. When this becomes irritated, inflamed

or obstructed -it can progress to diverticulitis. This can be complicated or uncomplicated. The

diverticulitis can spontaneously resolve without treatment or can progress to perforation and/or

abscess. Most patients will present with abdominal pain and change in bowel habits, and

sometimes fever. Routine care can include outpatient monitoring by PCP, change of diet and/or

antibiotics. When the patient experiences perforation, abscess or signs of sepsis, hospital

admission is required. CT scan of the abdomen/pelvis with IV contrast is the standard for

radiology evaluation for diagnosis, PO contrast can be included if able. CBC can be obtained to

assist in evaluation of both in-patient and out-patient for leukocytosis. The patient will require

alteration in diet or NPO status, GI and/or surgery consultation, antibiotics, and/or pain

management. Cancer can sometimes be the cause of diverticulosis to progress to diverticulitis,

and the patient should have an out-patient screening colonoscopy when diverticulitis has

resolved. Pertinent positives: leukocytosis, tachycardia, abdominal pain, fever, CT scan – abscess

near colon, patient age of 40’s, diarrhea. Pertinent negatives: CT scan read of ruptured

appendicitis

Crohn’s Disease K 50.90

Crohn’s Disease is an autoimmune disease of the intestines which can affect the colon. Crohn’s

disease can present with chronic symptoms of diarrhea, abdominal pain and/or blood in stool.

Crohn’s patient can have swelling and inflammation of the bowels, which can result in scarring

and strictures of the bowel. Crohn’s patients can also have perforation of the bowels due to

inflammation and swelling. Patients presenting with abdominal pain, and possible Crohn’s

should have routine labs sent (CBC/BMP) and a CT scan of abd/pelvis with IV contrast, PO

contrast if able. If Crohn’s is suspected, GI should be consulted. If perforation, the patient will

require antibiotics. If a patient with Crohn’s has perforation or stricture, specialized surgical

consult should be obtained, Colorectal if possible. Definitive diagnosis is with pathology from

GI biopsy or surgical sample. Pertinent positives: Anemia, fever, tachycardia, hypotension,

diarrhea, abdominal pain, CT scan read of abscess in pelvis. Pertinent negatives: No hx of

chronic GI symptoms, no noted thickening of bowel walls on CT scan.

Final Diagnosis:

Ruptured appendicitis with intra-abd abscess K 35.33

The appendix is an organ that comes off of the base cecum. When it becomes inflamed or

obstructed, it can rupture, allowing enteric bacteria into the sterile peritoneal cavity. Some

uncomplicated appendicitis can resolve without treatment. Appendicitis is typically diagnosed by

complaints of 1-2 days of abd pain, possible fever, typically negative for nausea, vomiting,

diarrhea. Appendicitis can be diagnosed on abd exam: RLQ pain to palpation, peritonitis (LLQ

rebound tenderness – Rovsing’s sign). Elevated WBC on CBC. If avoiding radiation in children

or pregnant women, US or MRI can be ordered. Standard diagnosis involves CT scan Abd/pelvis

with IV contrast. Appendicitis can be treated with IV and/or PO antibiotics if uncomplicated,

with the understanding that the patient has higher risk for recurrent appendicitis in future.

Appendicitis can be treated with appendectomy, typically laparoscopic. With ruptured

appendicitis with abscess, there is significant inflammation in the peritoneal cavity – and IR

drain of abscess, culture of fluid, and appropriate antibiotics is the primary treatment, with

interval Appendectomy as an out-patient when the patient has recovered. If the patient fails

antibiotic/IR management, they can require an appendectomy in-patient and this has increased

risk of requiring an open procedure, requiring an ileocecectomy, post-op intra-abdominal

abscess, intra-op injury to ureters, etc. If the patient is female, TOA, PID, ovarian cyst, and

ovarian torsion could be considered in the differentials.

PLAN
Treatment (Tx) Plan:

1. Acute ruptured appendicitis with abscess: As per Surgery/IR – will plan for IR perc drain

of intra-abd abscess. Send fluid for culture. Continue Zosyn as ordered for 10 days of

antibiotic therapy. Leukocytosis improving, lactate improving, Pressors continued for

hypotension, low UO with AKI. Fluid resuscitation.

2. Resp Failure – ABG WNL today. Wean vent to extubation, O2 per protocol. Pulmonary

toilet IS, cough and deep breathe Q1H while awake.

3. AKI: IVF resuscitation to improve UO, BP, and Creatinine, goal wean Levophed off and

maintain SBP >90: 1000cc bolus NS now, strict I&O, continue foley.

4. Nutrition: NPO until cleared by Surgery, continue stress ulcer prophylaxis.

5. DVT prophylaxis: continue heparin SQ/SCD, begin OOB activity, PT/OT eval and treat.

6. Labs: Replace Hypokalemia – 40Meq KCl over 4 hours IV and recheck Serum K in 4

hours. Recheck anemia, thrombocytopenia and AKI in am: CBC, Basic Metabolic Panel.

Patient seen and evaluated with Dr. Hardin.

Patient Education: Educate patient on ruptured appendicitis: plan for antibiotics and IR drain.

Plan to advance patient activity, resume PO intake when cleared by surgery. If bowel function

returns and abdominal exam is non-tender – will transfer to MedSurg and plan to go home and

see Surgery Out-patient. Discharge may include drain and antibiotics. If labs, vitals, bowel

function and abdominal exam do not improve to normal- patient may be re-evaluated for surgery

this admission.

Prognosis Good, Fair, or Poor: Good

Referral/Follow-up: Outpatient primary care due to AKI. Outpatient surgery clinic for Interval

appendectomy when abscess is resolved. If patient goes home with drain – will need to follow up

at IR clinic.

Disposition: Goal to progress to MedSurg in 1-2 days, plan for d/c home < 7 days. If patient has

drain at home, consider home health referral.

Reference(s):

www.iknowalot.comm – Use appropriate APA

www.allthehealthinfo.comm – Use appropriate APA

www.betterthangoogle.comm – Use appropriate APA

APPENDIX A

PREVENTATIVE CARE SCHEDULE (Example – not all-inclusive)

Preventive Care Date Result Referrals Made

Pap

Mammogram

A1C

Eye Exam

Monofilament

Test

Urine

Microalbumin

Diet/Lifestyle

Modifications

Digital Rectal

Exam (DRE)

PSA

Colonoscopy or

FOBT

Dexa Scan

CXR

BNP

ECG

Echo

Stress

Test

Vaccines