NursingDiagnosis PatientGoals Intervention:Rationale Implementation… Nursing DiagnosisPat

NursingDiagnosis PatientGoals Intervention:Rationale Implementation… Nursing DiagnosisPatient GoalsIntervention: RationaleImplementation(Yes or No)EvaluationOutcomeProvide Nursing diagnosis, Patient goals, intervention, implementation, Evaluation.  Based on your conversation with Mr Jones ( You can make one up but the patient did say he didn’t want to live anymore) Construct a soap note. Soap notes can be very brief but they must first have Subjective Data- What the patient tells you. Using quotes is good. Objective Data- lab values that are critical, vital signs what you observe that is important Assessment- What you assess ( ie more pain medication needed, remains suicidal etc) Plan- Did you call the doctor, did you continue same px etc.  See this example below:S- Patient states that he generally has been doing well. Depressive symptoms have improved but he still feels down at times. He is sleeping better, achieving 7-8 hours of restful sleep each night. He feels the medication is helping somewhat and without any noticeable side-effects. He has no suicide plan and has not thought about suicide since the recent attempt. He has no access to prescription medications, other than the fluoxetine. He believes the classes he participated in while inpatient have helped him with coping mechanisms. He has also coordinated individual counseling with his case manager.O- Vitals: T 98.4, P 82, R 16, BP 122/78General: alert and oriented to person, place, and time. Affect is significantly improved with good rangeof emotional expression.Heart- RRR, no murmurs, no gallopsLungs- CTA bilaterallySkin- no lesions or rashesLabs: CBC, lytes, and TSH all within normal limitsA- Major Depressive Disorder, recurrent, without psychotic featuresP- Continue Fluoxetine at 10mg dose. If no further improvement in the next week, we will consider increasingdose to 20mg. Continue outpatient counseling. Follow-up in one week or earlier if any depressive symptomsworsen.  Health Science Science Nursing NURSING N129 Share QuestionEmailCopy link Comments (0)

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