Mary Elliott is in Room 463-SOAP Documentation

Mary Elliott is in Room 463, and her hospital ID is 021481. Her birthdate is 02/14/1987, and she was admitted on 02/22/22 at 0815. Ms. Elliott complains of shortness of breath that worsens every time she gets up to walk a short distance, for example, the bathroom or when she changes position in the bed.

Her pulse is strong and regular 3+. She appears pale and is coughing frequently and continues to cough up large amounts of greenish yellow sputum. Her respirations are 32 bpm, labored and is using her accessory muscles to breath, substernal retractions and use of sternoclavicalmastoid muscles. Her skin is warm and moist.

Her SPO2 (pulse oximeter) is 90% without oxygen. Her pulse is 92 bpm and regular. You review the MD orders and note that the MD orders are to apply supplemental oxygen at 3 (three) liters a minute using a nasal cannula for oxygen delivery. The nurse orders a bedside commode for the patient’s use. The nurse instructs the client to not get up without assistance.

Approximately 10 minutes after the nurse applies the oxygen the SP02 is reading 96%, her respirations are 28 bpm and even, the client has no substernal retractions and occasionally using her accessory muscles the sternoclavicalmastoid muscles. Her mucous membranes are moist and pin and her skin is warm and dry.

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