soap charting flashcards

Normal Temperature

36–38°C (96.8–100.4°F)

Normal Adult Pulse

60–100 beats/min

Normal Respiratory Rate

12–20 breaths/min

Normal SpO₂

Usually 95–100% in most adults

Bradycardia

Heart rate less than 60 beats/min

Symptoms of Bradycardia

Dizziness, weakness/fatigue, fainting, and hypotension

Tachycardia

Heart rate greater than 100 beats/min

Causes of Tachycardia

Fever, pain, anxiety, exercise, dehydration, and hypoxia

Tachypnea

Respiratory rate greater than 20 breaths/min

Bradypnea

Respiratory rate less than 12 breaths/min

Fever

Elevated body temperature; 39°C (102.2°F) is a fever

Effects of Fever

Can increase heart rate, respiratory rate, sweating, chills, and flushed skin

Temperature Increase

As temperature increases, heart rate usually increases

Hypothermia

Body temperature below normal; 35°C (95°F) is an example

Nursing Care for Hypothermia

Keep the client warm, use warming blankets when appropriate, monitor vital signs, and watch for complications

Radiation

Heat loss from the body to a cooler surrounding surface or environment without direct contact

Conduction

Heat loss through direct contact with a cooler object or surface

Convection

Heat loss caused by moving air or fluid around the body

Evaporation

Heat loss when liquid on the skin changes into vapor, such as sweating

Sweat

Heat is lost through evaporation

Proper BP Technique

Client should be relaxed, with feet supported and legs uncrossed

Correct BP Cuff Size

Use the correct cuff size for the client's arm

BP Cuff Placement

Place the cuff on the bare arm

Cuff Artery Marker

Align the artery marker with the brachial artery

BP Cuff Location

Place the cuff 2–3 cm (about 1 inch) above the antecubital space

Arm Position for BP

Arm should be supported at heart level

Why Correct Cuff Size Matters

An incorrect cuff size can cause an inaccurate blood pressure reading

BP Documentation

Record BP, arm/site, client position, and method/equipment when needed

BP Documentation Example

BP 118/72 mm Hg, right arm, sitting

Brachial Artery

Artery in the upper arm used as the reference point for blood pressure cuff placement

Normal Adult Pulse

60–100 beats/min

Pulse Strength 0

Absent

Pulse Strength 1+

Weak or faint

Pulse Strength 2+

Normal

Pulse Strength 3+

Strong

Pulse Strength 4+

Bounding

Apical Pulse Location

5th intercostal space at the left midclavicular line

When to Count Apical Pulse for 60 Seconds

When an accurate measurement is needed or with certain cardiovascular medications

Apical Pulse

Heartbeat heard directly over the apex of the heart using a stethoscope

Normal SpO₂

Usually 95–100% for most adults

SpO₂ 93–94%

Assess the client and compare the reading with their baseline and clinical condition

Factors Affecting Pulse Ox

Poor circulation, cold extremities, movement, nail polish/artificial nails, and poor peripheral perfusion

Capillary Refill Less Than 2 Seconds

Generally indicates adequate peripheral perfusion

Pulse Ox and BP Cuff

Avoid placing the pulse oximeter on the same extremity as an automatic BP cuff when possible

Acute Pain Activates

The sympathetic nervous system and fight-or-flight response

Effects of Acute Pain

Can increase heart rate, blood pressure, respiratory rate, pupil dilation, and sweating

Pain Vital Sign Pattern

Pain can cause HR ↑, BP ↑, and RR ↑

Orthostatic Hypotension

A drop in blood pressure after changing position, especially when standing

Orthostatic Vital Sign Order

Supine → Sitting → Standing

Symptoms of Orthostatic Hypotension

Dizziness, lightheadedness, weakness, fainting, and increased fall risk

First Orthostatic Measurement

Start with the supine/baseline measurement

Athletes and Resting Heart Rate

Athletes may normally have bradycardia or a lower resting heart rate

Why Athletes Have Lower Resting HR

Improved cardiovascular conditioning can result in a lower resting heart rate

Assessing a Low HR in an Athlete

Consider the client's normal baseline and whether the client has symptoms

SOAP Charting

S = Subjective, O = Objective, A = Assessment, P = Plan

S – Subjective

What the patient reports or tells the nurse

Subjective: Fullness

Patient reports feeling full after lunch

Subjective: Shoulder Discomfort

Patient reports left shoulder stiffness/discomfort with movement

Subjective: Pain

Patient reports pain rated 3/10 with movement

Subjective: ROM

Patient reports shoulder feels better after range-of-motion exercises

Subjective: Nausea/Vomiting

Patient denies nausea and vomiting

Subjective: Dizziness/SOB

Patient denies dizziness or shortness of breath

Subjective: Comfort

Patient states she is comfortable after linen change

O – Objective

Observable, measurable, or directly assessed findings

Objective: Mental Status

Patient is awake and alert

Objective: Orientation

Patient is oriented to person and place

Objective: Weakness

Left-sided weakness noted

Objective: ROM

Limited range of motion of the left upper and lower extremities

Objective: Meal Intake

75% creamy strained chicken soup, 50% cream of wheat, 100% applesauce, 4 oz milk, and 2 oz apple juice

Objective: ROM Intervention

ROM performed as tolerated

Objective: Linen Change

Occupied bed linens changed due to spilled liquid/soiling

Objective: Tolerance

Patient tolerated procedures without acute distress

Objective: Repositioning

Patient repositioned comfortably

Objective: Safety

Call light within reach

SOAP Vital Signs

T 98.4°F, P 78, R 18, BP 138/78, SpO₂ 97% on room air

A – Assessment

The nurse's interpretation or clinical judgment about the patient's findings

Assessment: Left-Sided Weakness

Left-sided weakness related to CVA

Assessment: Limited ROM

Limited range of motion of left extremities

Assessment: Shoulder Discomfort

Mild left shoulder discomfort with movement

Assessment: Meal Intake

Partial meal intake

P – Plan

The nursing actions or interventions planned based on the assessment

Plan: Intake

Continue to monitor meal and fluid intake

Plan: ROM/Mobility

Continue ROM and mobility interventions according to the plan of care

Plan: Pain

Monitor pain and tolerance of activity

Plan: Safety

Maintain patient safety and comfort

Plan: Reporting

Report significant changes or concerns to the appropriate nurse/instructor