Kozier & Erb's Fundamentals of Nursing 10th Edition by Shirlee Snyder,Audrey Berman,Geralyn Frandsen

Exercise 3

Anderson, an 80-year-old male, was admitted for back pain. He has a past medical history of hypertension. He told the admitting nurse that he has lost interest in many of his normal activities because of the constant pain.
You read the following documentation entry by a previous nurse:
8-Client is a complainer. I listened to him for 15 minutes with no success. BP 210/90 and 180/70. P 72, R 18.
12-Refused lunch.
2-Client fell out of bed.
Sort the following pieces of data for Mr. Anderson into a SOAP note:
a. "I didn't sleep last night"
b. Positioned on side with pillows behind back c. Continues to need narcotic medication to progress toward goal of pain relief d. States pain is 8 out of 10 e. "I feel better" (after interventions) f. Last medicated 5 hours previously g. Heating pad applied to lower back h. BP 210/90, P 72, R 18 i. Add to plan of care to offer analgesic around the clock q4h versus pm j. 6/6/15 #1 Pain k. "Sharp, stabbing pain in lower back that radiates to left leg"
I. Medicated with ordered analgesic