Nurses/nps/mds: make a soap note: assessing the heart, lungs, and | Biology homework help
NURSES/NPs/MDs: Make a SOAP Note: Assessing the Heart, Lungs, and Peripheral Vascular System karfhrasuewnMake a SOAP Note: Assessing the Heart, Lungs, and Peripheral Vascular System
Scenario 2
Vital signs:
Temperature: 97.9 oral Respiratory rate: 32, labored Heart rate: 112, tachycardic BP right arm: 148/88 Oxygen saturation: 90% on room air Weight: 210 lbs, stable Skin: Cool, diaphoretic Thorax and lungs: Thorax symmetrical; diminished breath sounds right middle and lower lobes; no rales, rhonchi, or wheezes; breath sounds vesicular with no adventitious sounds left lung Cardiovascular: Heart rate is irregular with good S1, S2; no S3 or S4; no murmur Abdomen: Protuberant with normoactive bowel sounds auscultated x4 quadrants Peripheral vascular: Right calf with 2+ edema, erythema; warmth and tenderness on palpation noted; left lower extremity without edema or erythema; 2+ dorsalis pedis pulses bilaterally ------------------------------------------------------------------------------------------------------------------------------- Instructions: Your Discussion post should be in the SOAP Note format, rather than the traditional narrative style Discussion posting format. Refer to the Comprehensive SOAP Template/Exemplar on the attachments below.