Free Nursing Soap Note Template
Nursing Soap Note
Prepared by: [Your Name]
I. Subjective (S)
A. Patient's Reported Symptoms
The patient, a 55-year-old male, reports feeling lightheaded and weak when standing. He states the symptoms began two days ago and have progressively worsened. He also complains of a mild headache and occasional dizziness but denies chest pain or shortness of breath.
B. Patient's Medical History
-
Hypertension for 5 years
-
Type 2 diabetes
-
No known drug allergies
C. Patient's Medication
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Lisinopril 20 mg daily
-
Metformin 500 mg twice daily
II. Objective (O)
A. Vital Signs
|
Vital Sign |
Measurement |
|---|---|
|
Blood Pressure |
150/90 mmHg |
|
Heart Rate |
88 beats per minute |
|
Respiratory Rate |
18 breaths per minute |
|
Temperature |
98.7°F (37°C) |
B. Physical Examination Findings
|
Examination Area |
Findings |
|---|---|
|
Skin |
Warm, dry, and pale |
|
Head |
No signs of trauma; mild tenderness noted in the frontal area |
|
Cardiovascular |
Regular rhythm, no murmurs, pulse strong |
|
Neurological |
Alert and oriented to time, place, and person; no signs of confusion or loss of coordination |
|
Extremities |
Slight swelling noted in both ankles; no edema |
C. Lab Results
|
Lab Test |
Result |
|---|---|
|
Blood Glucose |
120 mg/dL |
|
Complete Blood Count |
Within normal limits |
III. Assessment (A)
A. Primary Concern
The patient’s lightheadedness and weakness are likely related to his hypertension and possible medication side effects. Mild swelling in the ankles may indicate early signs of fluid retention, potentially due to medication or poor circulation.
B. Secondary Concerns
The patient's blood pressure is elevated, which could be contributing to his symptoms of dizziness and lightheadedness. No signs of acute distress were noted during the physical exam.
IV. Plan (P)
A. Immediate Actions
-
Continue monitoring vital signs, particularly blood pressure and blood glucose levels.
-
Assess the patient’s fluid status, including input/output and ankle swelling.
-
Encourage the patient to change positions slowly to prevent further dizziness.
B. Medications
-
Review current medications for potential side effects. Consider adjusting lisinopril dosage or switching to an alternative antihypertensive agent.
-
Continue metformin as prescribed.
C. Follow-Up
-
Schedule a follow-up appointment in 2 weeks to reassess symptoms and blood pressure.
-
Recommend a visit to the primary care provider for further evaluation of hypertension management.
