SOAP Note on Incarcerated hernia Comprehensive Nursing Paper Example

SOAP Note on Incarcerated hernia Comprehensive Nursing Paper Example

Client ID:  32-year-old African American female

Subjective.

Chief complaint: The client complains of “abdominal pain.”

Source of reliability: Reliability of information is good. The client is an adult.

Present illness:The client complains of sudden pain on the right side of the abdomen. The pain began yesterday and has increased in severity. She takes Ibuprofen and Meclizine to manage pain and nausea, respectively, with no significant relief. The patient describes the pain as excruciating, pricking, and weakening. The client reports bloody stools, constipation, nausea, fatigue, and vomiting.  The client rates the pain at 9/10 without medication and 7/10 with medication. (SOAP Note on Incarcerated hernia Comprehensive Nursing Paper Example)

Past Medical Hx:

Medical history: No reported respiratory, cardiovascular, gastrointestinal, CNS, genitourinary, or musculoskeletal issues. (SOAP Note on Incarcerated hernia Comprehensive Nursing Paper Example)

Current Medications:

1. Ibuprofen 200mg po qd for pain.
2. Meclizine 100mg po qd for nausea

Surgical history: No previous surgical procedure.

Allergies: Pollen allergy

Current psych meds: None.

Past psychiatric history: Diagnosed with a major depressive disorder as a teenager. The condition was treated through medication (Amitriptyline 100mg po qd) and talk therapy. (SOAP Note on Incarcerated hernia Comprehensive Nursing Paper Example)

Substance use/abuse: Alcohol.

Past family, social history:

Family psych hx: Had an abusive relationship with her estranged husband. Has a history of alcohol abuse.

Social hx: Had a normal childhood development. Drinks occasionally while out with friends. She denies driving while drunk. She is a Christian and attends an Anglican Church on Sundays. (SOAP Note on Incarcerated hernia Comprehensive Nursing Paper Example)         

Education/Employment/Disability: Graduate of Education Science and a teacher at a local high school.The client is outgoing and free with people around her.

Primary support system: Suffered physical abuse from her estranged husband. The client has supportive parents.

Hobbies: Like adventure and gardening.

Review of systems (ROS):

General: Fever, nausea, and vomiting.

HEENT: No headaches. No vision loss. No loss of hearing or sense of smell. No sore throat. 

Skin: Normal turgor, nor rash or itching. (SOAP Note on Incarcerated hernia Comprehensive Nursing Paper Example)

Cardiovascular: No chest pain, pressure, or discomfort.

Respiratory: Increase heart rate. No cough.

Gastrointestinal: denies: Anorexia. Reports n/v/. Reports abdominal pain and bloody stool.

Genitourinary:  No burning urination. No Pregnancy. Last menstrual period, 09/02/2021.

Musculoskeletal: No joint pain or swelling.

Abdominal: No bowel movements/sounds. Sense of fullness.

Neurologic: No seizures or numbness. Limited bowel movement. Inability to pass gas.

Endocrine: Reports frequent urination (polyuria). (SOAP Note on Incarcerated hernia Comprehensive Nursing Paper Example)

Objective.

Vital Signs: Stable

Temp: 98.9 F, BP: 121/80, HR: 71, R: 16, O2: 93, Ht: 5’7’’, Wt: 130lbs, BMI: 21.6

Appearance: Well kempt and appropriately dressed. Makes good eye contact.

Attitude/interaction: Calm and interactive. Appears restricted

Activity level/behavior: In no acute distress. No psychomotor retardation or agitation.

Orientation: Alert and oriented in all spheres. (SOAP Note on Incarcerated hernia Comprehensive Nursing Paper Example)

Speech: clear and fluent, sounds anxious

Thought content/process/perception: Logical, linear, and goal-oriented.

Mood/affect: Mood is congruent with affect. Appear upbeat.

Judgment/insight/cognitive/memory: Normal judgment and insight. Memory is grossly intact.  Normal ability to abstract.

Attention: Noted some attention and concentration problems during the exam

Physical Exam:

Abdomen: Normal abdominal symmetry. Tenderness on the lower right abdomen.

Musculoskeletal: Full ROM in all extremities. No edema, clubbing, or effusion. (SOAP Note on Incarcerated hernia Comprehensive Nursing Paper Example)

LABS:

NAAT test: Negative

HCG: Negative

Tox screen: Negative

Assessment.

Diagnosis:

1. Incarcerated hernia: Results from the trapping of the intestine in the inguinal canal. Symptoms include acute pain, inability to move bowel, nausea, vomiting, and fever (Hope, Cobb, & Adrales, 2017) as presented by the patient. This is the primary diagnosis. (SOAP Note on Incarcerated hernia Comprehensive Nursing Paper Example)

Differential Diagnosis:

• Strangulated hernia:  Occurs when intestines become trapped, blocking blood flow (Pastorino & Alshuqayfi, 2021). Symptoms include sudden and acute onset of pain, nausea, vomiting, bulging hernia (red/purple/dark in color), and obstipation (Hope et al., 2017). This diagnosis is refuted.
• Appendicitis: Appendicitis is the inflammation of the appendix. Symptoms include sudden pain that progresses from the navel towards the lower right of the abdomen, abdominal bloating, nausea, vomiting, constipation, flatulence, general malaise, frequent urination and urgency, and diarrhea (Jones et al., 2021). This diagnosis is refuted. (SOAP Note on Incarcerated hernia Comprehensive Nursing Paper Example)
• Pelvic inflammatory disease (PID): PID is an inflammation of the upper genital tract caused by infections (Jennings & Krywko, 2020). Primary symptoms include progressively severe lower abdominal pain, abdominal tenderness, fever, and vaginal discharge (Dains, Baumann & Scheibel, 2018). This diagnosis is refuted.

Plan.

Probable diagnostic tests necessary for the diagnosis of abdominal pain include:

1. A physical exam is crucial in evaluating objective signs and symptoms associated with abdominal pain to inform the diagnostic reasoning for primary or secondary causes (Dains et al., 2018).
2. Pelvic examination: Pelvic examination is crucial for women to rule out other causes of abdominal pain such as PID (Dains et al., 2018). (SOAP Note on Incarcerated hernia Comprehensive Nursing Paper Example)
3. Computed tomography and magnetic resonance imaging: CT and MRI scans are vital in determining other causal factors such as hernias, appendicitis, or PID (Dains et al., 2018).
4. WBC count and ESR: Elevate WBC count, and ESR can rule out PID (Dains et al., 2018).

Treatment

Since there is no suspected strangulation:

1. Place the patient in a supine position
2. Have the hip padded at 30⁰ and have the hip and the knee flexed
3. Administer 50 mg/ml intramuscular analgesic tramadol to facilitate manual reduction (Yang & Liu, 2014) (SOAP Note on Incarcerated hernia Comprehensive Nursing Paper Example)
4. Hold the patient’s head with one hand and press the sac towards the inguinal canal until all the hernial contents return into the abdomen cavity
5. Prescribe Acetaminophen 300mg q6h for pain relief.

Specialist Referral

Refer the patient to a hernia specialist/doctor for further examination and recommendation.

Patient Education and Counselling

1. Explain to the patient their condition and Let the patient know that hernias are common and treatable. Thus, watchful waiting and prompt medical attention are necessary (Andresen & Rosenberg, 2018).  (SOAP Note on Incarcerated hernia Comprehensive Nursing Paper Example)
2. Avoid strenuous tasks/lifting heavy objects, fatty/sugary/acidic/high fiber foods, and smoking.
3. Maintain a healthy weight.  

The client is to return to the clinic after every week for further assessments and recommendations.

References

Andresen, K., & Rosenberg, J. (2018). Management of chronic pain after hernia repair. (SOAP Note on Incarcerated hernia Comprehensive Nursing Paper Example) Journal of pain research, 11, 675. https://doi.org/10.2147/JPR.S127820

Dains, J. E., Baumann, L. C., & Scheibel, P. (2018). Advanced Health Assessment & Clinical Diagnosis in Primary Care E-Book. Elsevier Health Sciences. (SOAP Note on Incarcerated hernia Comprehensive Nursing Paper Example)

Hope, W. W., Cobb, W. S., & Adrales, G. L. (Eds.). (2017). Textbook of hernia. Springer International Publishing. (SOAP Note on Incarcerated hernia Comprehensive Nursing Paper Example)

Jennings, L. K., & Krywko, D. M. (2020). Pelvic inflammatory disease. In StatPearls [Internet]. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK499959/  

Jones, M.W, Lopez, R.A., Deppen, J.G., & Kendall B.A. (2021). Appendicitis (Nursing). In: StatPearls. StatPearls Publishing, Treasure Island (FL). PMID: 33760471. (SOAP Note on Incarcerated hernia Comprehensive Nursing Paper Example) https://europepmc.org/article/NBK/nbk568712

Pastorino, A., & Alshuqayfi, A. A. (2021). Strangulated Hernia. StatPearls [Internet]. https://www.ncbi.nlm.nih.gov/books/NBK555972/

Yang, X. F., & Liu, J. L. (2014). Acute incarcerated external abdominal hernia.(SOAP Note on Incarcerated hernia Comprehensive Nursing Paper Example) Annals of translational medicine, 2(11). https://dx.doi.org/10.3978%2Fj.issn.2305-5839.2014.11.05