Case Analysis

Instructions: Read the scenario carefully and answer the questions based on

the concepts of documentation and reporting.

Scenario:

Mr. Anderson, an 80-year-old male, was admitted for back pain. He has a past

medical history of hypertension. He told the admitting nurse that he has lost

interest in many of his normal activities because of the constant pain.

You read the following documentation entry by a previous nurse:

8—Client is a complainer. I listened to him for 15 minutes with no success. BP

210/90 and 180/70. P 72, R 18.

12—Refused lunch.

2—Client fell out of bed.

1. What guidelines were not used in this documentation?

2. The nursing diagnosis for Mr. Anderson is Acute Pain. What would you expect

to document?

3. Using the following pieces of data for Mr. Anderson, sort them into a SOAP

note:
a. “I didn’t sleep last night”

b. Positioned on side with pillows behind back

c. Continues to need narcotic medication to progress toward goal of pain relief

d. States pain is 8 out of 10

e. “I feel better” (after interventions)

f. Last medicated 5 hours previously

g. Heating pad applied to lower back

h. BP 210/90, P 72, R 18

i. Add to plan of care to offer analgesic around the clock q4h versus prn

j. 6/6/11 #1 Pain

k. “Sharp, stabbing pain in lower back that radiates to left leg”

l. Medicated with ordered analgesic

1. The guidelines in the information that i have not found in the documentation are:
Firstly is the "Date" and time which the document haven't included which is one of the
important things to be done in the documentation in order to keep up the frequency of
records.
Second is the "Timing" which need to be followed by the agency as the for the
frequency of documentation of the clients health.
Third is the " Signature" of the previous nurse that has been checking on Mr. Anderson
in the documentation.
Fourth is the " Sequence" of the of the information of the client comment.

2
. The patient states being in a state of acute pain of sharp, stabbing pain in lower back
that radiates to left leg, and be expected to be a case of hypertension with a chance of
having a possible case of “Sciatica”

3.

SOAP NOTE

Subjective

 Patient stated “ I didn’t sleep last night”

 Patient states the pain as 8 out of 10

 Patient was last medicated 5 hours previously

 Patient reported “ Sharp, stabbing pain in lower back that radiates to left leg”

 Patient said “ I feel better after interventions”

Objective

 Blood Pressure 210/90

 Pulse Rate of 72

 Respiratory rate of 18

Assessment

 6/6/11 #1 Pain

Planning

 Positioned on side with pillows behind back

 Continues to need nacrotic medication to progress toward of goal relief

 Heating pad applied to lower back

 Add to plan of care to offer analgesic around the clock q4h versus prn

 Medicated with ordered analgesic