SOAP 1/2
SOAP (subjective, objective, assessment, plan) notes are a frequently used format for documenting client data including health history, physical examination, assessment or diagnosis, and plan of care. The nurse should be familiar with SOAP notes, how to interpret the initial history and physical (H&P) SOAP notes, and how to follow subsequent progress SOAP notes so as to maintain abreast of changes in the client's plan of care.
SOAP（主观、客观、评估、计划）记录是常用的患者资料记录格式，内容包括健康史、体格检查、评估或诊断和医疗计划。护士应熟悉SOAP记录，知道如何解读初级病史和体检（H&P）SOAP记录及如何跟踪后续进展SOAP记录，以便与患者医疗计划的变化保持一致。 A. Subjective 主观资料 1. Identifying client information
确认患者信息
Name, date of birth, medical record number
姓名、出生日期、病历号 2. Problems, allergies, medications, immunizations (PAM) lists
问题、过敏、用药、免疫接种（PAM）清单
Ongoing list of medical problems, allergies with reactions, medications with dosages and directions, and past immunizations
疾病、过敏反应、药物剂量和说明、既往免疫接种等更新清单 3. General client information
患者一般信息
Address, phone numbers, employer, work address and phone number, email address, gender, marital status, health insurance status and information
地址、电话号码、单位、工作地址和电话、电子邮箱、性别、婚姻状况、健康保险状况和信息 4. Chief complaint or reason for seeking care
主诉或求诊理由
Brief description of main problem; stated verbatim in quotation marks; duration is always included
主要问题的简单说明；逐字陈述，用引号；持续时间 5. History of present illness
现病史
Detailed description of all symptoms that may be related to the chief complaint
可能跟主诉有关的所有症状的详细说明
Guided by “OLDCARTS" symptom analysis: (onset, location, duration, character, aggravating/associated factors, relieving factors, timing, severity)
“OLDCARTS”指导下的症状分析：（起病、部位、持续时间、性质、加重/相关因素、缓解因素、频率、严重程度） 6. Past medical history
既往医病史
Hospitalizations, surgeries, childhood illnesses, adult illnesses, injuries/accidents, immunizations, past and current medications, allergies, mental health, recent laboratory tests
住院史、手术史、童年时疾病、成人疾病、损伤/意外、免疫、既往/当前用药、过敏史、心理健康史、最近化验资料 7. Family history
家族史
Pedigree may be included 可以包括家谱
Includes but not limited to major health or genetic disorders, such has hypertension, cancer, cardiac, respiratory, and thyroid disorders, allergies, hepatitis
包括但不限于：重大健康或遗传疾病，如高血压、癌症、心脏病、呼吸系统疾病和甲状腺病；过敏；肝炎
Age and health of spouse and children included 包括配偶和子女的年龄及健康状况 8. Personal and social history
个人与社会史
Varies based on health influences 随健康影响而变
Cultural background and practices, home environment, general life satisfaction, safety/abuse, stressors, religious preferences, occupation, exposure to heat/cold or toxins, exposure to contagious diseases, health habits such as diet, exercise, smoking, salt intake, obesity, alcohol intake, recreational drug use, caffeine use, sexual activity, concerns about cost of care.
文化背景和做法；家庭环境；总体生活满意度；安全/虐待；压力；宗教倾向；职业；热/冷或毒素暴露情况；触染性疾病暴露情况；健康习惯，如饮食、运动、吸烟、盐摄入、肥胖、饮酒、娱乐药使用、咖啡因使用、性生活、对医疗费用的担心等。 9. Review of systems (may include some objective data)
系统回顾（可包括某些客观资料）
General or constitutional symptoms: fever, chills, malaise, night sweats, fatigue, unintentional weight loss or gain, overall behavior
一般或全身症状：发烧、寒战、不适、盗汗、疲劳、意外体重减轻或增加、整体表现
Skin, hair, nails: rash, itching, pigmentation change, sweating, abnormal hair or nail growth
皮肤、毛发、指甲：皮疹、发痒、色素沉着变化、出汗、毛发或指甲异常生长
Head and neck: headache, dizziness, syncope, concussions, loss of consciousness
头、颈：头痛、头晕、晕厥、脑震荡、失去意识
Eyes: visual acuity, double vision, blurring, light sensitivity, glaucoma, use of glasses or contacts, use of eyedrops
眼：视敏度、复视、视力模糊、光过敏、青光眼、使用眼镜或隐形眼镜、使用眼药水
Ears: hearing loss, ear pain, tinnitus, vertigo
耳：听力丧失、耳痛、耳鸣、眩晕
Nose: smell, colds, nosebleeds, postnasal discharge, sinus pain
鼻：嗅觉、感冒、鼻衄、鼻后滴、窦痛
Throat and mouth: hoarseness, change in voice, sore throat, gum bleeding-or swelling, taste changes
喉、口腔：声嘶、声音变化、咽喉痛、牙龈出血或肿、味觉改变
Lymphatics: enlargement, tenderness
淋巴管：肿大、触痛
Chest and lungs: respiratory pain, dyspnea, wheezing, cyanosis, cough, sputum, hemnoptysis, last chest x-ray
胸和肺：呼吸痛、呼吸困难、哮鸣、紫绀、咳嗽、痰、咯血、末次胸透
Breasts: development, pain, tenderness, lumps, discharge, last mammogram
乳房：发育、疼痛、触痛、肿块、分泌、末次乳房X线检查
Heart and circulation: chest pain, edema, history of hypertension, myocardial infarction, exercise tolerance, previous cardiac tests, claudication, bruising, thrombophlebitis
心脏与循环：胸痛、水肿、高血压史、心肌梗塞、运动耐受性、既往心脏检查、跛行、擦伤、血栓性静脉炎
Hematologic: anemia, blood cell disorder, bleeding
血液学检查：贫血、血细胞疾病、出血
Gastrointestinal: appetite, food intolerance, dysphagia, heartburn, nausea, vomiting, diarrhea, constipation, change in stool, dark urine, previous studies such as colonoscopy, diet recall
胃肠：胃口、食物不耐受、吞咽困难、胃灼热、恶心、呕吐、腹泻、便秘、粪便变化、黑尿、既往检查如结肠镜检查、日常饮食回忆
Endocrine: thyroid enlargement, heat or cold intolerance, polyphagia, polydipsia, polyuria, changes in facial or body hair, striae
内分泌：甲状腺肿大、热或冷不耐受、多食、多饮、多尿、面部或身体毛发变化、皮纹
Genitourinary: for males, puberty onset, testicular pain, libido, infertility; for females, menses onset, regularity, duration, dysmenorrhea, last period, itching, date of last Papanicolaou (Pap) smear/human papilloma virus (HPV) test, age at menopause, libido, sexual difficulties, pregnancy (GTPAL: refer to Chapter 17); for both, dysuria, flank pain, urgency, frequency, nocturia, dribbling, hematuria, incontinence
生殖泌尿：男性：青春期开始，睾丸痛，性欲，不育；女性：月经初现，规律性，持续时间，痛经，上次月经，发痒，末次Pap/HPV检查时间，停经年龄，性欲，性困难，妊娠（GTPAL，参见第13章）；男女：排尿困难，胁腹痛，尿急，尿频，夜尿，尿淋漓，血尿，尿失禁
Musculoskeletal: joint pain, stiffness, redness, swelling, restricted motion, deformities
肌肉骨骼：关节痛，僵硬，红，肿，活动受限，变形
Neurological: syncope, seizures, weakness, paralysis, incoordination, tremors, cognition
神经学：晕厥，癫痫发作，无力，麻痹，共济失调，震颤，知觉
Mental health: mood changes, depression, anxiety, difficulty concentrating, suicidal thoughts, irritability, sleep disturbances
精神健康：情绪变化，抑郁，焦虑，注意力集中困难，自杀念头，易激惹，睡眠障碍
★Vocabulary for Today ★
SOAP -- subjective, objective, assessment, plan
主观、客观、评估、计划
health history – 健康史
physical examination – 体格检查
H&P – history and physical examination病史和体格检查
abreast of – 与…保持并列，不落后于，与…保持一致
medical record number – 病历号，医疗档案号
ongoing – a. 进行的，前进的
marital status – 婚姻状况
health insurance – 医疗保险
chief complaints – 主诉
verbatim – a. ad. 逐字（的）
history of present illness – 现病史
past medical history 既往病史
current medications – 当前用药
family history -- 家族史
genetic disorders – 遗传性疾病
personal history – 个人史
social history -- 社会史
life satisfaction – 生活满意度
review of systems -- 系统回顾
eye drops -- 眼药水
tinnitus – n.耳鸣
postnasal discharge -- 鼻后滴
hemoptysis – n. 咯血
mammogram – n. 乳房X线检查
polyphagia – n. 多食
polydipsia – n. 多饮
So, you’re one month out….
Deep breathing, meditation, yoga, and a glass of fine wine – it’s time to clear the way ahead and dig in.
How do you go about it?
So glad you asked. Here’s the one month study game plan. Let’s break it down into 3 categories:
Get Prepared
Master the Content
Master the Questions Step 1 – Get Prepared
I know organization may not be your thing – I mean, just look at the state of your car.
But, before diving in on question banks or NCLEX-RN prep tests, it’s important to set yourself up for success with a plan. This small amount of upfront effort will maximize focus and time – Remember you only have one month! Failing to do so will waste time, energy, and potentially cause more stress and anxiety as your NCLEX-RN date comes closer. 1-1: Review how the NCLEX-RN works
The exam is unique relative to most exams out there. It uses Computer Adaptive Quizzing (CAT) to evaluate you. So, rather than being completely in the dark as to what you’re heading into, head over to this Magoosh posting for more info on what to expect. Things like ‘how many questions will I receive?’ and ‘when will the exam end?’ are covered there. 1-2: Review about the types of questions on the NCLEX-RN
Haha! You thought it would be multiple choice only, huh? Well guess again. The exam boasts various types of questions including:
Ordered Response (place the answers in sequential order)
Select All That Apply
Fill in the Blank (Math)
Drag and Drop
Hotspot (click a location on a diagram)
Chart/Exhibit/Diagram
Audio
Being prepared to answer all these types of questions will ease anxiety and build confidence. 1-3: Set the study time aside
Even with a month window (which seems fast), studying will seem like a marathon. However, setting aside chunks of time at regular intervals will provide the best study experience. Should you study for 30 minutes at a time or 3 hours? It depends on you and your study habits. However, make sure you allocate enough time to cover the content you want – especially problem areas. Remember: regular study sessions at regular intervals will help ease stress and prevent the night before cram! Step 2 – Master the Content
Don’t know what you don’t know? Welcome to my world. Luckily there’s an app for that… and online resources, prep courses, books, and flashcards. All these options have various price ranges and various time commitments. Choose the best fit for you and stick with it. 2-1: Take a self evaluation
This is a crucial step! Working diligently on the “problem” categories and brushing up on the “piece-of-cake” ones is recommended. If you don’t know where your blind spots are, you’re likely to be surprised when these questions arise. 2-2: Map out a content calendar
Now that you know your strengths and weaknesses, it’s time to map out the 4-5 weeks. A general rule of thumbs is to dedicate the beginning and the end of your study calendar to your problem areas. So, for example, if you lack maternity skills, begin week 1 in maternity and end week 5 in maternity. The middle weeks are for reinforcing the rest. If you realize there are micro areas (like math or lab values) that need extra attention, I recommend starting and ending each study session with a focused review – practice writing out lab values when you begin and when you finish your studying. Over the course of 4-5 weeks, they will be so ingrained in your memory, you’ll be recalling lab values while you sleep! Step 3 – Master the Questions 3-1: Practice, practice, practice
You should be completing at least 100+ practice questions daily. There’s no getting around it. This list on helpful hints for navigating questions is generic but proven to be imperative:
Read the questions entirely
Identify which part of the nursing process the questions is asking about
Find key words
Rule out answers
Use critical thinking – ABC’s, nursing process, Maslow’s Hierarchy of needs.
You have only one month – remember……. Deep breathing, meditation, yoga, and a glass of fine wine. You’re going to do great!
★Test ★
1. A Spanish-speaking client arrives at the triage desk in the emergency department and states to the nurse, “No speak English, need interpreter.” Which is the best action for the nurse to take?
A. Have one of the client’s family members interpret.
B. Have the Spanish-speaking triage receptionist interpret.
C. Page an interpreter from the hospital’s interpreter services.
D. Obtain a Spanish-English dictionary and attempt to triage the client. 2. The nurse is performing a neurological assessment on a client and elicits a positive Romberg’s sign. The nurse makes this determination based on which observation?
A. An involuntary rhythmic, rapid, twitching of the eyeballs
B. A dorsiflexion of the ankle and great toe with fanning of the other toes
C. A significant sway when the client stands erect with feet together, arms at the side, and the eyes closed
D. A lack of normal sense of position when the client is unable to return extended fingers to a point of reference
答案 Key to Questions 1. D Rationale: The best action is to have a professional hospital-based interpreter translate for the client. English-speaking family members may not appropriately understand what is asked of them and may paraphrase what the client is actually saying. Also, client confidentiality as well as accurate information may be compromised when a family member or a non–health care provider acts as interpreter. 2. C Rationale: In Romberg’s test, the client is asked to stand with the feet together and the arms at the sides, and to close the eyes and hold the position; normally the client can maintain posture and balance. A positive Romberg’s sign is a vestibular neurological sign that is found when a client exhibits a loss of balance when closing the eyes. This may occur with cerebellar ataxia, loss of proprioception, and loss of vestibular function. A lack of normal sense of position coupled with an inability to return extended fingers to a point of reference is a finding that indicates a problem with coordination. A positive gaze nystagmus evaluation results in an involuntary rhythmic, rapid twitching of the eyeballs. A positive Babinski’s test results in dorsiflexion of the ankle and great toe with fanning of the other toes; if this occurs in anyone older than 2 years it indicates the presence of central nervous system disease.
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