Simchart Soapi Note Example

Assignment: Assignment #2--Friday-Professor ...
P, M
Health Care Provider: R S
Sex: F
Weight: 189 lbs 10 oz
Code Status: 01
Isolation: 00
Food Allergies: 00
Diet: 01
Hospital Floor:
Age: 53 Y
Height: 5' 9"
Alerts: 00
Drug Allergies: 03
Env. Allergies: 00
BMI: 28
Psychiatric
Student: Rebecca Sopelak Assignment: Assignment #2--Friday-Professor Harnage-RMH Submitted: 04/19/2015 17:31
Clinical Assignment Grading
Assignment Objectives
No assignment objectives entered.
Clinical Set-up Details
First Day of Clinical:
04/17/2015
Primary Diagnosis:
Major depressive
disorder, recurrent,
moderate
Provider Name:
S, R
Secondary Diagnosis:
Student Details:
Diabetes mellitus
Patient Details:
First Initial:
Identifier 1: M
Last Name:
Sopelak
Identifier 2: P
Credentials:
SN
Gender:
Age:
53 Years
Pre-Clinical Manager
Patient Info Identifier: P, M
Gender: F
Age: 53 Y
Nurse Initials: R Sopelak, SN
Diagnosis (2)
Primary Diagnosis:
Major depressive disorder, recurrent, moderate
Patho-Physiology:
Depressed mood with loss of pleasure in previously enjoyable activities that has been occurring for at least 2 weeks.
Therapeutic Regimen:
-Current Health Problems and Related Functional Changes:
53 year old female referred by Arbor House. She has been there for 19 days, but has been feeling physically ill. The
staff said she's being sent to the ED for flu-like symptoms, but has also expressed suicidal ideations. At this time, they
feel that she's not medically stable enough to return to Arbor House after being checked out. Upon meeting with the
patient today, she said that Arbor House took her off her Effexor her first week there. She said she started feeling ill,
then they restarted her on her Effexor 3-4 days ago. The patient said she feels "detached and out of control". She said
that she doesn't feel as if she can care for herself at this time. The patient feels scared and not stable. At this time, she
endorses suicidal ideation two times a day. Patient was admitted to the BHU.
Secondary
Diagnosis:
Diabetes mellitus
Patho-Physiology:
Type 2
Increased insulin resistance on the cells resulting in a lack of insulin production from the pancreas
Therapeutic Regimen:
--
Current Health Problems and Related Functional Changes:

-Medications (6)
Medication:Trazodone Tablet
Classification:
Antidepressant: other
Route:
Oral
Frequency:HS
Dose:
Date
50 mg
01/01/1900
Ordered:
Comments and Additional Medication Info:
Therapeutic Effect:
For depression mood stabilization and regulation
Stabilizes mood and behaviors
Action:
Inhibits the reuptake of serotonin Antagonize serotonin
Contraindications:
No contraindications Caution with children, pregnant
at low doses (<1 mg)
women, and breastfeeding women
Side Effects or Adverse Reactions:

Headache Muscle ache Nausea, vomiting, loss of
appetite Constipation, diarrhea Sexual dysfunction
Dizziness Dry mouth or eyes. Numbness, burning,
tingling
Life Threatening Considerations:

Can increase suicidal ideation with increased mood, so
watch patients very carefully who have a plan in place.
Black box warning in use with children
Recommended Dose Ranges:

150 mg/day, max dosage 400 mg/day
Nursing Interventions:
Assess patient daily for suicidal ideation Monitor for
signs of suicide Watch for an improvement in mood (can
mean that the medication is working or that the patient
has enough energy to act upon any thoughts of suicide
or homicide)
Medication:Clonidine Tablet - (Catapres)
Classification:
Antihypertensive
Route:
Oral
Frequency:HS
Dose:
Date
Ordered:

For insomnia
Therapeutic Effect:
Sleep aid
Action:
Stimulation of presynaptic alpha-2-receptors in the
brainstem thus inhibiting the sympathetic outflow from
the central nervous system
Contraindications:
anuria sulfonamide hypersensitivity thiazide diuretic
hypersensitivity

Constipation Decreased sexual ability Dry, itching, or
burning eyes Loss of appetite Nausea or vomiting
Blurred vision

Don't give to patients in ESRD Don't give if BP is less
than 100/60

0.6 mg/day (for hypertension)
Take blood pressure before administering, if BP is
<100/60, don't administer and call the provider
Medication:Topiramate Tablet - (Topamax)
Classification:
Anticonvulsant: other
Route:
Oral
Frequency:HS
Dose:
Date
Ordered:

For sleep and migraines
Therapeutic Effect:
Aids in insomnia and migraine prophlaxis (from the
0.1 mg
01/01/1900
50 mg
01/01/1900
withdraw of Effexor)
Action:
Contraindications:
-reduces the duration of abnormal discharges and the

number of action potentials within each discharge -
none
enhances the activity of the inhibitory neurotransmitter

GABA at GABA-A receptors by increasing the
frequency at which GABA activates GABA-A receptors topiramate inhibits excitatory transmission by
antagonizing some types of glutamate receptors
vision problems burning, prickling, or tingling
Don't stop immediately
unsteadiness confusion dizziness drowsiness eye

redness
25 mg/day PO
Monitor for side effects Have patient sit on the side of
the bed before getting up because the medication can
cause dizziness Help patient move if vision problems
occur Give at night if patient is prone to the side effect of
drowsiness Advise patient against taking during the day
and driving/operating machinery if they get drowsy on
the medication
Medication:Clonidine Tablet - (Catapres)
Classification:
Antihypertensive
Route:
Oral
Frequency:dailly (morning)
Dose:
Date
Ordered:

For anxiety
Therapeutic Effect:
Suppress CNS to reduce feelings of anxiety
Action:
Stimulation of presynaptic alpha-2-receptors in the
brainstem thus inhibiting the sympathetic outflow from
the central nervous system
Contraindications:
anuria sulfonamide hypersensitivity thiazide diuretic
hypersensitivity

Constipation Decreased sexual ability Dry, itching, or
burning eyes Loss of appetite Nausea or vomiting
Blurred vision

Don't give to patients in ESRD Don't give if BP is less
than 100/60

0.6 mg/day (for hypertension)
Take blood pressure before administering, if BP is
<100/60, don't administer and call the provider
Medication:Desvenlafaxine Extended Release Tablet (Pristiq)
Classification:
Antidepressant:
serotonin/norepinephrine reuptake
inhibitor
Route:
Oral
Frequency:daily
Dose:
Date
Ordered:

for depression
Therapeutic Effect:
promotes mood stabilization
Action:
prevents the reuptake of serotonin and norepinephrine
Contraindications:
desvenlafaxine hypersensitivity MAOI therapy
0.05 mg
01/01/1900
50 mg
01/01/1900
to allow for more of these neurotransmitters in the
venlafaxine hypersensitivity
postsynaptic space, thus more to uptake by the synapse

to improve mood
increased sweating dizziness, drowsiness loss of
Black box warning advising against the use in children
appetite tightness in jaw mild nausea, constipation sleep
Can increase suicidal ideations
problems (insomnia) sexual dysfunction

50 mg PO once daily, max dose is 400 mg/day
Monitor for signs of suicidal ideation Assess patient for

suicidal thoughts and plans If patient has suicidal
thoughts prior to use, monitor for improvement in
mood. Improvement in mood can give them the energy
to follow through on a plan.
Medication:Mirtazapine Tablet - (Remeron)
Classification:
Antidepressant: other
Route:
Oral
Frequency:HS
Dose:
Date
Ordered:

for sleep
Therapeutic Effect:
aid in the ability to sleep
Action:
antagonism at central pre-synaptic alpha2-receptors
causing an increase in NE release
Contraindications:
none

dizziness drowsiness dry mouth weakness high
cholesterol constipation increased appetite weight gain

Black box warning against use in children Can increase
suicidal ideations

15 mg PO at bedtime
Have patient sit on the side of the bed before getting up
to prevent dizziness Help them if they have weakness
Educate the patient not to drive or operate machinery if
they have drowsiness
7.5 mg
01/01/1900
Laboratory Tests (4)

Laboratory
Test:
Complete Blood Cell Count (CBC)
Definition and Description:

-Significance of the Test Being Ordered for this Patient:
-CBC: RBC
Test
5.08
Result:
Result
Level:
Within Normal Limits
Result Significance:
-CBC: Hgb
Test
13.7
Date of
Test:
04/16/2015
Result:
Result
Level:

-CBC: Hct
Test
Result:
43.7
Result
Level:

-CBC (RBC Indices): MCV
Test
86.0
Result:
Result
Level:
-CBC (RBC Indices): MCH
Test
27.0
Result:
Result
Level:
-CBC (RBC Indices): MCHC
Test
31.4
Result:
Result
Level:
-CBC (RBC Indices): RDW
Test
15.2
Result:
Result
Level:
-CBC: WBC
Test
7.5
Result:
Result
Level:
-CBC: Blood Smear
Test
--
Result:
Result
Level:
Not done with this test
CBC: Platelet Count
Test
273
Result:
Result
Level:

-CBC: MPV
Test
--
Result:
Result
Level:
Laboratory
Test:
Comprehensive Metabolic Panel

-Comprehensive Metabolic Panel: Albumin
Test
3.7
Result:
Result
Level:
-Comprehensive Metabolic Panel: Bilirubin
Test
0.3
Result:
Result
Level:
-Comprehensive Metabolic Panel (Bilirubin): Indirect
Test
-Result:
Result
Level:
Comprehensive Metabolic Panel (Bilirubin): Total
Test
-Result:
Result
Date of
Test:
04/16/2015
Level:
Comprehensive Metabolic Panel (Bilirubin): Direct LDL
Test
-Result:
Result
Level:
Comprehensive Metabolic Panel: BUN
Test
Result:
10
Result
Level:

-Comprehensive Metabolic Panel: Calcium
Test
9.2
Result:
Result
Level:
-Comprehensive Metabolic Panel: CO2
Test
24
Result:
Result
Level:
-Comprehensive Metabolic Panel: Chloride
Test
108
Result:
Result
Level:
High
She hasn't had an appetite recently, so she hasn't been eating much. Starvation can elevate chloride levels
Comprehensive Metabolic Panel: Creatinine
Test
0.74
Result:
Result
Level:
-Comprehensive Metabolic Panel: Alkaline Phosphatase
Test
97
Result:
Result
Level:

-Comprehensive Metabolic Panel: Potassium
Test
4.3
Result:
Result
Level:
-Comprehensive Metabolic Panel: Protein (Total)
Test
7.1
Result:
Result
Level:

-Comprehensive Metabolic Panel: Sodium
Test
143
Result:
Result
Level:
-Comprehensive Metabolic Panel: AST
Test
14
Result:
Result
Level:
Low
AST levels are normally low in the body
Comprehensive Metabolic Panel: Glucose
Test
101
Result:
Result
Level:
-Laboratory
Test:
Urinalysis

-Urinalysis: Appearance
Test
clear
Result:
Result
Level:
Date of
Test:
04/16/2015

-Urinalysis: Color
Test
yellow
Result:
Result
Level:
-Urinalysis: Odor
Test
none
Result:
Result
Level:

-Urinalysis: pH
Test
6.5
Result:
Result
Level:
-Urinalysis: Protein
Test
negative
Result:
Result
Level:
-Urinalysis: Specific Gravity
Test
1.017
Result:
Result
Level:
-Urinalysis: Leukocyte Esterase
Test
negative
Result:
Result
Level:
-Urinalysis: Nitrites
Test
negative
Result:
Result
Level:

-Urinalysis: Ketones
Test
50
Result:
Result
Level:
High
She hasn't been eating so this could possibly be from the lack of food intake causing her body to break down her
protein stores.
Urinalysis: Crystals
Test
Result:
negative
Result
Level:

-Urinalysis: Casts
Test
negative
Result:
Result
Level:
-Urinalysis: Glucose (24-hour urine)
Test
negative
Result:
Result
Level:
-Urinalysis: Glucose (fresh urine)
Test
negative
Result:
Result
Level:
-Urinalysis: WBC
Test
negative
Result:
Result
Level:
-Urinalysis: WBC Casts
Test
negative
Result:
Result
Level:
-Urinalysis: RBC
Test
negative
Result:
Result
Level:

-Urinalysis: RBC Casts
Test
Result:
negative
Result
Level:

-Laboratory
Test:
Toxicology (other) (Substance Abuse

Testing (other))
Date of
Test:
04/16/2015

-Toxicology (other) (Substance Abuse Testing (other))
Test
-Result:
Result
Level:
Everything was negative except for two things. She was positive for ecstasy and benzodiazapines
Diagnostic Tests (1)
Diagnostic
Test:
Echocardiography
Date of
Test:
04/17/2015
Definition and Description of the Test:

She has no diagnostics on file with RMH. Her open heart surgery was done at Mary Washington Hospital, so they have
the files on her EKG, X-rays, etc.
Significance of the Test Being Ordered for this Patient:
-Significant Findings and Results:
-Clinical Grading:
Clinical
Grade:
20
Remarks:
All details competed in this section, well done.
Care Plan Details

Care Plan
Priority
1
Medical Diagnosis: Major depressive disorder,
Created By: R Sopelak, SN 04/19/2015 | 17:12
recurrent, moderate
Nursing Diagnosis: Social isolation
Modified By: R Sopelak, SN 04/19/2015 | 17:18

Status:
Active
Type:
Actual
Related To
Alterations in mental status
Altered state of wellness
Inability to engage in satisfying personal relationships
Evidenced By
Absence of supportive significant other(s)
Dull affect
Expresses feelings of aloneness imposed by others
Insecurity in public
Seeks to be alone
Expected Outcome
Measurement/Time Frame
Comments
Patient will identify
by discussing two ways to improve

her feeling of being alone by the en
d of the shift.
She told us that she knows she can call h

er husband and come to groups to help h
er feel less isolated, but still chose to sta
y in her room.
by coming to groups once a day for

the rest of her stay.
Despite encouraging, she decided to sta

y in her room all day
feelings of isolation.
Patient will initiate

interactions with others
and set and meet goals.
Interventions
Rationale
Comments
Assessing personal space needs,

communication style, acceptable body
language, attitude toward eye contact,
perception of touch, and paraverbal
messages when communicating with the
to help aid in her feeli

ngs of isolation
She wanted to remain alone and pr

eferred to sleep. We encouraged h
er to at least get up and shower. S
he did make eye contact, but not m
uch helped to get her to come be m
ore involved on the floor.
She isn't from close to

here, so her family ca
n't come see her that
often, so discuss way
s to aid with this.
She is from around the Manassas a

rea which isn't very close to RM
H. Her family can't always find the ti
me to come visit every day. She al
so hasn't heard from her kids for 2
months.
by encouraging her to
come out her room as
often as she can.
We encouraged her to come out ev

ery time we were in the room. We
also told her to listen to the announc
ements to come to any groups that
she feels up to.
patient
Discussing/assessing causes of perceived
or actual isolation
Encouraging the patient to initiate contacts

with self-help groups, counselors, and
therapists
Establishing a therapeutic relationship
to promote trust and t
The patient did trust us and asked u
he feeling of safety an
d less loneliness in th
s for our help.
e patient
Priority
2
Medical Diagnosis: Major depressive disorder,
recurrent, moderate
Nursing Diagnosis: Hopelessness

Status:
Active
Type:
Actual
Related To
Deteriorating physiological condition
Long-term stress
Prolonged activity restriction resulting in isolation
Evidenced By
Decreased affect
Decreased appetite
Lack of initiative
Lack of involvement in care
Sleep pattern disturbance
Expected Outcome
Comments
Patient will make eye

contact and focus on the
during every interaction with others f

or the rest of the shift
She did make eye contact when spea

king to anyone who entered the room.
by sleeping 6-8 hours a night with on

ly one 30 minute nap a day for the re
st of her stay.
She slept more than not during the shi

ft. Her naps were often 2-3 hours lon
g on top of sleeping for about 6 hours
a night.
speaker.
Patient will sleep an
appropriate length of time
for age and physical health.
Interventions
Rationale
Comments
Assessing the patient

for isolation within the
because she's not curren

tly near her family, so this
can cause her to feel isol
ated from them
She is far from her family and they can't see her ever
yday. We encouraged her to call them as often as s
he would like to make herself feel more apart of her f
amily while she was away.
to help improve further tre

atment of her disease
I assisted the nurse practitioner with her assessment

of the patient. She did suggest changing her medic
ations to hopefully improve her mood and get her ba
ck to her normal level prior to her depressive sympto
ms.
to determine the effective

ness of her care and if m
edications need to be alt
ered or changed
The patient had suicidal ideations, but no plan.
to help her make informe

d decisions about her car
I helped teach the patient about her new medication t

o keep her informed of her care.
family unit
Discussing knowledge
of and previous
experience with the
disease
Monitoring and
documenting the
potential for suicide
Providing accurate
information
e
Taking threats of self-
because those treats cou
When placing a call bell in her bed, we made sure to
harm or suicide
ld be for attention or they
zip tie the cord. Although, she claims to have no pla
seriously
could be real and she co

uld follow through with the
n, her increasing suicidal ideations were concerning

and needed to be taken seriously because as they in
creased, she could very well try to take her own life.
Priority
3
Medical Diagnosis: Diabetes mellitus
Nursing Diagnosis: Imbalanced nutrition, Risk
for imbalance more than body requirements

Status:
Active
Type:
Actual
Related To
Dysfunctional eating pattern
Parental obesity
Evidenced By
Dysfunctional eating pattern
Sedentary activity level
Expected Outcome
Comments
Patient will design dietary

modifications to meet
individual long-term goal of
by eating 3 balanced meals dur

ing the shift.
She skipped breakfast and didn't touch

much of her lunch. She claims that she h
as had a decreased appetite recently du
e to her medications and her depressio
n.
by getting up to walk the halls fo

r 30 minutes each day for the d
uration of stay.
She preferred to stay in her bed. She di

dn't even want to get up to shower.
weight control.
Patient will incorporate
appropriate activities
requiring energy expenditure
into daily life.
Interventions
Rationale
Comments
Assessing changes in
lifestyle and eating patterns
she has been consuming le

ss food due to lack of appe
tite
Her eating pattern has changed to a decreas

ed food intake. She is very sedentary right n
ow as well.
Encouraging the patient to

eat at least three servings of
to maintain a well rounded

diet
The patient at maybe two bits of her entire lun

ch and did not eat breakfast.
to help her determine if her

body weight is within health
y limits for her heart and dia
betes control
She didn't want to discuss her weight at this ti

me. She thought that treating her depression
was a more important path to pursue at this ti
me.
options
to help her maintain stable

blood glucose levels with h
er changing depression tre
atment medications
We talked about her medication changes an

d decided to keep her on the Janueva becau
se it was helping and keeping her blood suga
rs stable.
Recommending that the
to start the morning off with
We recommended her to eat a healthy breakf
whole grains per day

Helping the patient calculate
his or her body mass index
(BMI)
Providing the patient and
family with information
regarding treatment plan
patient eat a healthy
a good meal to provide ene
ast to start her metabolism and boost her blo
breakfast every morning
rgy for the day
od sugar to get her going for the day. Despit

e the recommendation she didn't want her br
eakfast.
Care Plan Grading:

Care Plan
Grade:
40
Remarks:
Well thought out treatment plan.
Charting Details
History and Physical
Psychiatric History
Patient Information
Chief Informant:
--
Chief Complaint:
--
History of Current
Problem:
--
Allergies:
--
Psychiatric History
Past Psychiatric History:
Previous Psychiatric Hospitalizations:
--
--
Suicide History:
Outpatient Treatment:
--
--
Alcohol Use:
Substance Use:
--
--
Electroconvulsive Therapy (ECT):

-Family History:
-Past Medical History

Previous Illnesses:
Contagious Diseases:
--
--
Injuries or Trauma:
Surgical History:
--
--
Dietary History:
Other:
--
--
Social History:
Current Medications:
--
--
Current Medications:
-Review of Systems
Integument:
HEENT:
--
--
Cardiovascular:
Respiratory:
--
--
Gastrointestinal:
Genitourinary:
--
--
Musculoskeletal:
Neurologic:
--
--
Endocrine:
Genitalia:
--
--
Lymphatic:
-Mental Status
Mental Status Examination
Appearance:
Behavioral Activity:
well groomed
depressed, lack of motivation to move from bed
Speech:
Thought Form:
normal
fears she can't contract for safety, racing thoughts
Thought Content:
Suicidal Impulses:
linear
suicidal ideation, no plan
Homicidal Impulses:
Orientation:
none
Oriented x4
Memory:
Mood:
short-term intact, long-term is a little bit foggy for the

past 6 (been in and out of hospitals for the past 6months, hard to differentiate the days)
depressed, anxious, tearful, isolated, lonely, hopeless,

helpless, irritable, decreased energy
Affect:
flat
Judgment and Insight:
Attention:
good insight and judgement
decreased concentration
Physical Examination
Physical Exam
General:
Vital Signs:
--
--
Integument:
HEENT:
--
--
Cardiovascular:
Respiratory:
--
--
Gastrointestinal:
Genitourinary:
--
--
Musculoskeletal:
Neurologic:
--
--
Developmental:
Endocrine:
--
--
Genitalia:
Lymphatic:
--
--
Impressions
Impression:
--
Plan:
--
Provider Signature:
--
Date:
01/01/0001
Time:
--
Progress Notes
Date
Progress Notes
04/18/2015 14:57
Axis 1: Major Depressive disorder, recurrent

Axis 2: deferred
Axis 3: diabetes
Axis 4: problems with health and support system
Axis 5: 45
Admission History
Signature
Created By: R Sopelak, SN

04/18/2015 | 14:24
Modified By: R Sopelak, SN 04/18/2015 |
14:37
Health History
Mental Health
Mood disorders
Endocrine Disorders
Diabetes:
Controls with oral medication
Years with diabetes:
Is compliant with diabetic regimen

unknown
Sexuality/Reproductive
Reproductive problems:
Abuse
Other Health History

Abuse (physical and sexual), triple bypass surgery (Dec 26,
2014)
Allergy Information
Do you have any known allergies to
Yes
drugs, food, or environmental items?

Allergy Info
Type
Allergen
Reactions
Severity
Informant
Confidence Entered By Entered

Level
Day/Time
Medicati
on
Penicillin
G
Benzanth
ine
Suspensi
on for
Injection (Bicillin
L-A,
Bicillin LA
Pediatric
)
unknown
Mild
Self
Moderat
ely
Reliable
R
Sopelak,
SN
04/18/20
15
14:25
Medicati
on
Lorazep
am
Tablet (Ativan)
Headach
e
Severe
Self
Moderat
ely
Reliable
R
Sopelak,
SN
04/18/20
15
14:26
Medicati
on
Atorvast
atin
Tablet (Lipitor)
Headach
e
Severe
Self
Moderat
ely
Reliable
R
Sopelak,
SN
04/18/20
15
14:26
Home Medication Information

Do you take any medications, herbal
products, vitamins, or supplements at
home?
No
Drug Screen
Street/Recreational/Excessive Prescription Drug Use
Has never used street/recreational/excessive prescription
drugs
Smoking Screen
Do you live with a smoker?
No
Smoker Status
I have never used tobacco.
Alcohol Screen
Do you drink alcohol?
No
Fall Risk Assessment

Morse Fall Scale
Fall Risk Assessment score:
15
Risk Level
Low risk
Fall Prevention Protocol
Fall prevention protocol in effect
Morse Fall Scale
History of Falling
No=0
Secondary Diagnosis
Yes=15
Ambulatory Aid
None/Bedrest/Nurse Assist=0
IV or IV Access
No=0
Gait
Normal/Bedrest/Wheelchair=0
Mental Status
Oriented to Own Ability=0
Total Fall Risk Score
Risk Score:
15
Fall Risk Score and Preventative Measures Implemented

Fall Risk Level:
Fall Risk Measures:
Low Risk
Implement <b>Low</b> Risk Fall Prevention
Interventions:<br>All admitted patients, orient to surroundings,
patient and family education about risk, toileting program, bed
in low position, evaluate medication response, personal items
in reach, night light as appropriate, nonskid footware,
decrease room clutter.

Psychosocial Screen
Psychiatric History
Out-patient treatment
Suicide history:
In-patient hospitalizations
Thoughts only
Life Stressors In the Past Year:
Death of a loved one

Medical problems
Safety Evaluation
Suicidal/homicidal impulses:
Passive
Current living situation:
With friend/family
Current employment situation:
Unemployed
House
Appearance
Grooming:
Clean, with good grooming
Behavioral Status
Calm/cooperative
Emotional Status
How do you feel right now?
Body language:
Over the past 2 weeks, have you felt
down, depressed, or hopeless?
Over the past 2 weeks, have you had
Anxious
Depressed
Hopeless
Sad
Tired
Slumped body posture
Yes
Yes
little interest in doing things?

Cognitive Ability
Orientation
Oriented to time:
Oriented to person:
Oriented to place:
Yes
Yes
Yes
Memory
Recall 5 object names 3 minutes after
mention?
Can recall place of birth?
Can recall year Born?
Can recall mother's maiden name?
Yes
Yes
Yes
Yes
Abstract Reasoning (Able to Report Logical Response)

A bird in the hand is worth two in the
Yes
bush:
A rolling stone gathers no moss:
Yes
Attention Span
Can correctly say the days of the
Yes
week:
Can correctly spell "world"
Yes
backwards:
Thought Formulation
Linear/goal directed
Thought Content
No abnormalities
Judgment
How well is patient meeting social
and family obligations?
What are your plans for the future?
Needs help
Appropriate
Comprehension
Can follow simple directions:
Can follow complex directions:
Yes
Yes
Aphasia
Can communicate verbally:
Yes
Patient Assets
Aptitude
Experiences
Education
Insight
Cooperation
Problem Areas
Attitude
Support system
Motivation
Decision Making Rating
Low Complexity: Minimal number of diagnoses, low risks of
complications/morbidity/mortality
Treatment Plan and Recommendations
Immediate need for any of the
following:
Safety plan (Low, Medium, Acute level)
Depression Evaluation
Patient Health Questionnaire (PHQ-9)
Over the last 2 weeks , how often have you been bothered by any of the following problems?
Little interest or pleasure in doing
Nearly every day
things:
Feeling down, depressed, or
Nearly every day
hopeless:
Trouble falling or staying asleep, or
Nearly every day
sleeping too much:

Feeling tired or having little energy:
Nearly every day
Poor appetite or overeating:
More than half the days
Feeling bad about yourself or that
Nearly every day
you are a failure or have let yourself or

your family down:
Trouble concentrating on things such
Several days
as reading the newspaper or

watching television:
Moving or speaking so slowly that
Not at all
other people could have noticed, or

the opposite being so fidgety or
restless that you have been moving
around a lot more than usual:
Thoughts that you would be better off
dead or of hurting yourself in some
way:
If you were bothered by any of these
problems, how difficult has the
problem made it for you to do your
work, take care of things at home, or
get along with other people?
Nearly every day
Somewhat difficult
PHQ-9 Scoring for Severity Determination

Total score:
21
Severe
Role/Relationship
Marital or Partner Status
Married
Family Processes
Participates as decision-maker in family
Caregiver Role
Family caregiver; works well
Role Performance
Good self-identity and role identity
Social Interactions
Describes self as outgoing and friendly
Culture/Spirituality
Are there religious, cultural, or ethnic
concerns we should consider while
you are in the hospital?
No
Do you want clergy to visit you while
No
you are in the hospital?

System Assessments
Symptom Analysis
Symptom Analysis
Chief Complaint:
"I was taken off of Effexor after 13 years and I think my

medications are messed up"
Cardiovascular Assessment
Pulses
Apical:
Regular
Murmur noted:
No
Ankle-brachial Index Test

Right arm systolic blood pressure:
Left arm systolic blood pressure:
100 mmHg
104 mmHg
Tissue Perfusion
Peripheral vascular, general:
Warm extremities
Edema
No edema noted
Capillary Refill
Left hand:
Left foot:
Right hand:
Right foot:
Mucous membranes color:
Mucous membranes moisture:
Less than 3 seconds

Less than 3 seconds
Less than 3 seconds
Less than 3 seconds
Pink
Moist
Cardiac Assessment
No cardiac problems noted
Telemetry
Continuous telemetry:
No
Respiratory Assessment
Respiratory Pattern
Even
Effortless
Oxygenation
Oxygen delivery system:
Chest Tube
Room Air
None
Gag Reflex
Present
Cough
Cough type:
None
Neurological Assessment
Level of Consciousness/Orientation
Oriented to person, place, time, and situation
Emotional State
Cooperative
Anxious
Sad
Crying
Flat affect
Hand Grip
Bilateral assessment:
Right hand grip strength:
Equal
Strong
Foot Pumps
Right foot strength:
Equal
Strong
Central Nervous System Assessment (CNS)

Headache
Integumentary Assessment
Skin Assessment
Color:
Within expected parameters for patient
Sensory Assessment
Vision Assessment
Blurred vision
Hearing Assessment
No hearing problems noted
Pupillary Equality
Equal
Size
Left pupil:
Right pupil:
3
3
Pupillary Reaction
Left eye reaction to light:
Brisk
Constricted
Right eye reaction to light:
Brisk
Constricted
Pupillary Accommodation
Accommodation present?
Yes
Musculoskeletal Assessment
Range of Motion (ROM)

Moves all extremities with full range of motion
Gait/Balance
Ambulates on own, steady gait
Gastrointestinal Assessment
Mouth/Gums/Teeth
Gums and mouth:
Teeth/bridges/dentures:
Good condition, no lesions or sores

Teeth in fair condition
Abdomen
Abdominal assessment:
Soft to palpation
Nontender to palpation
Gastrointestinal
Nausea
Intestinal
Stool characteristics:
Firm
Brown
No reported rectal problems
Rectum:
Pain Assessment
Do You Have Pain Now?
Yes
Frequency of Pain:
Constant
Intensity of Pain:
8
Behavioral Assessment of Pain Intensity:

Nonverbal Cues of Pain:
Anxiety
Quality of Pain:
Throbbing
Aggravating Factors:
Other
More information of
light and sound
Aggravating Factors:
aggravate (headache)
Relieving Factors:
Genitourinary Assessment
Rest
Nonnarcotic Medication
Urinary System Assessment

Urination mode:
Voiding
Urine Color/Characteristics
Color:
Urinary assessment:
Yellow, straw-colored
No urinary problems noted
Characteristics:
Clear
Odor:
No odor
Female
Female external genitalia
assessment:
No problems noted
Psychosocial Assessment
Safety Issues
Are you concerned you will harm
yourself?
Are you concerned you will harm
someone else?
Do you have a plan to harm yourself
or anyone else?
Yes
No
No
Daily Psychosocial Assessment

Daily Psychosocial Assessment
Perception
Think about your current health situation and all that it involves and rate your
understanding on a scale of 1 to 10, where 1 is "I have all the information I need" and 10
is "I need more information".
Support
Whom can you depend on to give you support during this time? Rate your sense of
support on a scale of 1 to 10, where 1 is "I have full support" and 10 is "I cannot depend
on anybody".
Coping
How are you dealing with your health situation? Rate your coping on a scale of 1 to 10,
where 1 is "I am coping very well" and 10 is "I am having difficulty coping".
10
Anxiety
How is your health situation affecting you? Rate your emotional state on a scale from 1 to
10, where 1 is "I am feeling calm" and 10 is "I am feeling terrified".
Objective Evaluation of Anxiety
Moderate anxiety: Patient displays muscle tension, appears nervous

Scoring
Total
24/40
Score:
A low score is indicative of a healthy psychosocial state.
Safety Assessment
Behavioral
Suicidal/homicidal impulses:
Passive
Orientation
Oriented to time, person, place
Bracelet Check
Hospital ID bracelet
Allergy bracelet
Discharge Planning
Created By: R Sopelak, SN 04/18/2015 |

14:38
Discharge Planning
Planning for Returning Home
What was your care status before this
admission?
What is your current living
arrangement?
What services have been established
for after discharge?
What is your anticipated discharge
destination?
Who will care for you after discharge?
To whom should discharge care
instructions be given?
Independent
Lives with family/relatives
None
Residential facility
Self
Self
Tentative needs before discharge

Treatment plan
Medication teaching
Motivational level
Seems anxious, fidgety
Basic Nursing Care
Safety
Fall Precautions
Fall-prevention education
Side rails encouraged

Bed in low position
Bed wheels locked
Call light within reach
Instructed to call nurse for assistance
Nonskid footwear in use
Door open unless contraindicated
Nurse-Patient Relationship Strategies for Safety
Potential for harmful behaviors determined
Patient encouraged to discuss future plans
Patient allowed to express feelings
Risk factors assessed , (i.e., history of past attempts)
Safety in Milieu
All potential of harm removed from milieu
Activity
Activity
Quiet room
Up without restrictions
Ambulation/Locomotion
Ambulates independently
Turning/Range of Motion
Turns self
Hygiene/Dressings/Comfort
Comfort
Elevate head of bed
Bath/Shower
Independent shower
Hair/Nails
Independent hair/nail care
Dressing
Dresses self
Clean hospital gown after bath
Nutrition and Hydration
Nutrition
Feeds self
Hydration
Drinks independently
Elimination
Functional Ability
Independent in toileting
Skin Care
Skin Care
Skin care products in use
Pressure Ulcer Reduction
Patient turns self
Vital Signs
Chart Time Temperature Respirations Pulse
Blood Pressure Oxygenation Notes
(F)
(Resp/min)
(Beats/min)(mmHg)
Entry By
04/18/2015 98.3
14:50
Site:
Forehead
R
Sopel
ak, SN
20
84
Site:
Radial
100/61
Site: Right
arm
Position: Lying
Height/Weight
Chart Time
Weight
(Pounds/Kgs)
Height (Feet
Inches/cm)
Notes
04/18/2015 14:51
189 lbs / 86 kgs

Adm
Bed scale
5' 9" / 175.3 cm
Entry By
R Sopelak, SN
General Orders
Code Status
Status:
Intervention:

Active
Full code
Nutrition
Cholesterol-Controlled Diet
Status:
Order Start Date:
Diet Type:
Consistency:
Active
04/17/2015 00:00
Cholesterol-Controlled Diet
Normal
Patient Card
Order
Description
Date/Time
Category
Status
Last
Discontinued Entry By
Performed By
04/17/2015 Full code
Code Status
Active
--
----
| 00:00
Sopelak,
SN
04/17/2015
00:00
04/18/2015 Severe Depression
Patient
| 14:34
Health
Sopelak,
Questionnair
SN
04/18/2015
Score
Active
--
----
14:34
04/17/2015 Normal
Cholesterol-
| 00:00
Controlled
Active
--
----
R
Sopelak,
Diet
SN
04/17/2015
00:00
04/19/2015 Major depressive

| 16:54
moderate-Social
isolation
Care Plan
Active
--
----
R
Sopelak,
SN
04/19/2015
16:54
04/19/2015 Major depressive

| 17:03
moderateHopelessness
Care Plan
Active
--
----
R
Sopelak,
SN
04/19/2015
17:03
04/19/2015 Diabetes mellitus| 17:12

Imbalanced nutrition,
Risk for imbalance
more than body
requirements
Care Plan
Active
--
----
R
Sopelak,
SN
04/19/2015
17:12
Charting Grading:
Charting
Grade:
40
Remarks:
Excellent details in this section.
Competencies
No competencies entered.
5
Remarks:
Overall Grading:
Care Plan
Grade:
40
Pre-Clinical Manager Grade:
20
Charting
Grade:
40
Overall
Grade:
100
Remarks:
Rebecca, You are doing excellent SOAPI notes in SIM, very good work. Dr. Harnage
Copyright 2015 Elsevier Inc. All Rights Reserved.

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Assignment: Assignment #2--Friday-Professor ...

Health Care Provider: R S

Weight: 189 lbs 10 oz

Height: 5' 9"

Nurse Initials: R Sopelak, SN

Major depressive disorder, recurrent, moderate

Current Health Problems and Related Functional Changes:

For depression mood stabilization and regulation

Stabilizes mood and behaviors

at low doses (<1 mg)

women, and breastfeeding women

Side Effects or Adverse Reactions:

Life Threatening Considerations:

Recommended Dose Ranges:

Medication:Clonidine Tablet - (Catapres)

Comments and Additional Medication Info:

Side Effects or Adverse Reactions:

Life Threatening Considerations:

Recommended Dose Ranges:

Medication:Topiramate Tablet - (Topamax)

Comments and Additional Medication Info:

-reduces the duration of abnormal discharges and the

enhances the activity of the inhibitory neurotransmitter

Life Threatening Considerations:

vision problems burning, prickling, or tingling

Don't stop immediately

unsteadiness confusion dizziness drowsiness eye

Medication:Clonidine Tablet - (Catapres)

Comments and Additional Medication Info:

Side Effects or Adverse Reactions:

Life Threatening Considerations:

Recommended Dose Ranges:

Medication:Desvenlafaxine Extended Release Tablet (Pristiq)

Comments and Additional Medication Info:

to allow for more of these neurotransmitters in the

postsynaptic space, thus more to uptake by the synapse

Life Threatening Considerations:

increased sweating dizziness, drowsiness loss of

Black box warning advising against the use in children

appetite tightness in jaw mild nausea, constipation sleep

Can increase suicidal ideations

problems (insomnia) sexual dysfunction

50 mg PO once daily, max dose is 400 mg/day

Monitor for signs of suicidal ideation Assess patient for

Medication:Mirtazapine Tablet - (Remeron)

Comments and Additional Medication Info:

Side Effects or Adverse Reactions:

Life Threatening Considerations:

Recommended Dose Ranges:

Laboratory Tests (4)

Complete Blood Cell Count (CBC)

Definition and Description:

Within Normal Limits

Within Normal Limits

Within Normal Limits

Comprehensive Metabolic Panel

Definition and Description: