Analysis of the SOAP Notes
Accurate planning of care depends on a proper assessment of the patient that leads to the correct diagnosis. As such, nurses have to be extra careful when writing the SOAP notes because it is though the SOAP notes that the nurses come up with differential diagnoses and the development of ideal care plans. The paper offers a critique of the SOAP notes associated with a patient suffering from a gastrointestinal condition.
Analysis of the Subjective Data Portion
Although elementary information regarding the patient is described in the subjective data portion, I feel that there are sections that have been left out. The family history of any patient presenting in a healthcare facility is important. Leaving the information regarding the family history of the patient makes it difficult to link the symptoms to a genetic condition. Additionally, I feel that the patient’s pain is not described in detail. An ideal patient pain description ought to be captured on a pain scale alongside distinct descriptive words such as ‘throbbing.’
Moreover, there is a significant need to elaborate on the patient’s bowel movement. The provided information reveals that the patient experienced diarrhea. However, the information leaves out the nature of the stool including such elementary characteristics such as the presence of blood in the stool. Including the type of food that the patient had before visiting the healthcare facility is also important. It is also imperative to include information on the history of gastrointestinal bleeding that the patient had including the area that the gastrointestinal bleeding affected.
Analysis of the Objective Data Portion
In as much as the basic information is captured in the objective data portion, some critical information is missing. It is important to capture the information on the general appearance of the patient. The nurse should state whether the patient is alert and oriented to time, name, and place. The objective data section equally fails to capture information related to the patient’s head, nose eyes, ears, and throat.
Additionally being that the patient is experiencing diarrhea, it is important to assess the integumentary system of the patient. Diarrhea often leads to dehydration that can best be detected by reviewing the integumentary system. It is essential to determine a review of the patient’s skin turgor, capillary refill, and mucus membrane. It is through the review of the system that the nurse can know the impact of diarrhea on the patient.
A critique of the Assessment Section
I feel that the assessment section lacks elementary information omitted in the subjective and objective sections of the SOAP notes. Additionally, it is ideal to base assessments on diagnostic test results to be sure of the correct assessment decision. I thus feel that the assessment in the presented SOAP notes is not ideal as it is not supported by certain elementary sections of the subjective and objective data.
Diagnostic Tests
One of the tests that should have been conducted is a stool test. Being that the patient experienced gastrointestinal bleeding in the last 4 years, conducting a stool test would reveal the presence of blood in the stool that points to GI bleed (Sugano et al., 2015). Conducting stool cultures will equally be ideal in knowing whether or not the patient has a bacterial infection. Additionally, being that the patient is experiencing diarrhea, it would be ideal to perform a basic metabolic panel to determine the electrolyte levels (Sugano et al., 2015). Fluid imbalances are common with patients who experience diarrhea. Additionally, I feel that the performance of a complete blood count would be ideal in knowing whether the patient is experiencing a recurrence of gastrointestinal bleeding.
Differential Diagnosis
Based on the provided patient information, I would accept viral gastroenteritis as a diagnosis. There are significant chances that the patient could be suffering from viral gastroenteritis. The patient presentations associated with viral gastroenteritis include abdominal pain, diarrhea, nausea, vomiting, and hyperactive bowel sounds (Barbara et al., 2016). Some of the patient’s presentations in the subjective and objective data sections are related to the signs of viral gastroenteritis hence a possible diagnosis. I however feel that the diagnosis would have been supported by various lab results.
Apart from viral gastroenteritis, I feel that the patient could be suffering from gastritis. Gastritis is a condition that is associated with the inflammation of the lining of the stomach (Sugano et al., 2015). The signs and symptoms of the condition may include diarrhea, vomiting, indigestion, and heartburn. A few of the signs of the condition are related to the patient’s presentation.
Gastritis could be another condition associated with the patient’s signs and symptoms. Gastritis is a condition that presents itself as a result of the inflammation of the lining of the stomach (Drossman, 2016). Apart from the pain, other signs and symptoms of the condition include vomiting, heartburn, and diarrhea. The patient, however, does not exhibit some of the signs and symptoms of the condition.
Diverticulitis could be another condition associated with the patient’s signs and symptoms. Diverticulitis is a gastrointestinal condition that is associated with bleeding from the rectum and discomfort in the left lower quadrant. The patient does not experience any form of bleeding from the rectum hence the condition is ruled out.
The patient’s condition could as well be associated with appendicitis. Appendicitis is a condition characterized by the inflammation of the appendix as a result of the accumulation of foreign bodies. An individual experiencing appendicitis exhibits symptoms such as vomiting, fever, nausea, and chills. The pain experienced by the patient on the left-lower quadrant rules out the possibility of appendicitis.
References
Barbara, G., Feinle-Bisset, C., Ghoshal, U. C., Santos, J., Vanner, S. J., Vergnolle, N., … & Quigley, E. M. (2016). The intestinal microenvironment and functional gastrointestinal disorders. Gastroenterology, 150(6), 1305-1318.
Drossman, D. A. (2016). Functional gastrointestinal disorders: history, pathophysiology, clinical features, and Rome IV. Gastroenterology, 150(6), 1262-1279.
Sugano, K., Tack, J., Kuipers, E. J., Graham, D. Y., El-Omar, E. M., Miura, S., … & Malfertheiner, P. (2015). Kyoto global consensus report on Helicobacter pylori gastritis. Gut, 64(9), 1353-1367.