NR 509 Week 5 Soap Note

Chamberlian School of Nursing

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Exam (elaborations) NR 509 Week 5 Soap Note
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November 2021

2021/2022
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Initials: EP Age: 78 Gender: Female Height: 5’2” Weight: 120 lbs BP: 110/70 HR:92 Temp: 37.0 C SPO2: 99 RR: 16 Pain (1-10): 6 Allergies: Medication: NKDA Food: none Environment: Latex—“itchy rash” History of Present Illness (HPI) Chief Complaint (CC): “pain in my belly” and difficulty going to the bathroom Onset: Constipation 5 days ago with the exception of an episode of was watery diarrhea 3 days ago Location: “low in abdomen” Duration: constant x 5 days C...
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