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Please write a respiratory SOAP on a patient that has RLL pneumonia. The note should reflect...

Please write a respiratory SOAP on a patient that has RLL pneumonia. The note should reflect physical assessment findings that you may find on this patient.

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Answer #1

Respiratory soap:

SOAP meaning

S = Subjective

O = Objective

A= Assessment

P = Plan

Subjective:

1. Difficulty in respiration

2. Chest pain

3. Restlessness

4. Rusty sputum

5. Fever

Objective:

1. Wheezing

2. Rales

3. Rhonchi

4. Crackles

5. Bubbling sound

These sounds are heard on auscultation.

Assessment:

1. Head to foot assessment

2. Respiratory assessment:

Assess for wheezing, rales, ronchi, bubbling sound crackers

Check for egophony

Nutritional support

Temperature

Mini mental status examination

Assess for associated problems

Plan:

1. Comfortable bed

2. Comfortable positions

3. Oxygen administration

4. Anti hyper thermic measures

5. Analgesics

6. Antibiotics

7. Continue to monitor ABG

8. Chest x rays and other diagnostic studies

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