Please write a SOAP note and SBAR for nursing. Strictly follow the format. Patient details

Please write a SOAP note and SBAR for nursing. Strictly follow the format. Patient details History of Present Problem: John Richards is a 45-year-old male who presents to the emergency department (ED) with abdominal pain and worsening nausea and vomiting the past three days that have not resolved. He is feeling more fatigued and has had a poor appetite the past month. He denies any ETOH (alcohol) intake the past week, but admits to episodic binge drinking on most weekends. John weighs 150 pounds (68.2 kg) and is 6’0″ (BMI 17.6). You are the nurse responsible for his care. Personal/Social History: John is single, has never married, and lives alone in his own apartment. He has struggled with heroin use/abuse in the past, but has not used in the past two years. John is currently unemployed and has no health insurance. He was diagnosed with hepatitis C ten years ago but has had minimal follow-up medical care since Current VS: P-Q-R-S-T Pain Assessment (5th VS):T: 100.5 F/38.1 C (oral) Provoking/Palliative: Nothing/nothingP: 110 (regular) Quality: AcheR: 20 Region/Radiation: RUQ/epigastricBP: 128/88 Severity: 6/10O2 sat: 95% RA Timing: Continuous Position: HR: BP:Lying 110 128/88Standing 132 124/80Current Assessment:GENERAL APPEARANCE:Appears uncomfortable, body tense, occasional facial grimacingRESP: Breath sounds clear with equal aeration bilaterally, nonlabored respiratory effortCARDIAC: Pink, warm & dry,1 pitting edema lower extremities, heart sounds regular-S1S2, pulses strong, equal with palpation at radial/pedal/post-tibial landmarksNEURO: Alert & oriented to person, place, time, and situation (x4)GI: Abdomen distended, large-rounded-firm to touch, bowel sounds audible per auscultation in all 4 quadrantsGU: Voiding without difficulty, urine clear/light orange, loss of pubic hairSKIN: Skin integrity intact, color normal for patient, sclera of eyes light yellow in color, lips and oral mucosa tacky dry, softball-sized ecchymosis on the abdomen. Medications: Establish peripheral IV NS 0.9% bolus of 1000 mL Ondansetron 4 mg IV every 4 hours PRN Orthostatic BP  Health Science Science Nursing NURSING 355 Share QuestionEmailCopy link Comments (0)

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