AGACNP ICU SOAP Note EXAMPLE
NURS XX Week 7 SOAP Note
Level of Care: ICU
Hospital Day: 2
Demographic Data : S.J. 42 year old Black female
Chief Complaint (CC): Nods head when asked if experiencing abd pain Unable to
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
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
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:
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.
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.
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.
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 40s, diarrhea. Pertinent negatives: CT scan read of ruptured
Crohns Disease K 50.90
Crohns Disease is an autoimmune disease of the intestines which can affect the colon. Crohns
disease can present with chronic symptoms of diarrhea, abdominal pain and/or blood in stool.
Crohns patient can have swelling and inflammation of the bowels, which can result in scarring
and strictures of the bowel. Crohns patients can also have perforation of the bowels due to
inflammation and swelling. Patients presenting with abdominal pain, and possible Crohns
should have routine labs sent (CBC/BMP) and a CT scan of abd/pelvis with IV contrast, PO
contrast if able. If Crohns is suspected, GI should be consulted. If perforation, the patient will
require antibiotics. If a patient with Crohns 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.
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 Rovsings 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.
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
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.
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PREVENTATIVE CARE SCHEDULE (Example not all-inclusive)
Preventive Care Date Result Referrals Made