SOAP
Subjective: This is a 3 year old male who was brought in by his mother due to nosebleeds for 2 days. Mother reports nosebleeds was on and off for 2 days. She reports moderate amounts of blood is produced each time. She reports this as the first time it has ever occurred. She reports the father and one daughter has problems with nosebleeds but denies any bruises noted. She denies any family hx of bleeding. She reports hx of allergies herself. She denies any bruising or other bleeding problems. She denies any nasal obstruction or allergy to medications or food. Denies fever, difficulty breathing, trauma, hoarseness, or dysphagia. She reports her son has a cold, runny nose, stuffiness, and sneezing for 3 days. She reports the child frequently rubs the nose. Reports nasal discharge to be clear and thin. Health promotion: Covers nose when sneezing.
Objective: Lungs clear. Temp 97.4. Nasal mucosa red, with clear, thin discharge, and mild bleeding noted. No swelling, foreign body, no external lesions. Able to smell pop corn and perfume.
Mouth: Mucous membranes moist, no lesions. Tongue moist, normal size, no fasciculation, does not deviate on extension. Teeth present.
Throat: Mucosa pink, no exudates. Uvula midline. Tonsils present. Gag reflex present.
Assessment: Ineffective breathing pattern r/t
Plan: Refer to Primary Care Provider.
Encourage increase in fluid intake.
Avoid OTC cough, cold medicines, and aspirin.
Avoid people with infection.
Avoid cold environments.
Air humidification, nasal spray, or nasal gel for added moisture, prevent crusting, and bleed.
Cover mouth and nose when sneezing or coughing.
Wash hands after touching nose or mouth and after coughing or sneezing.
Check pulse ox, keep above 90%.
Encourage child not to rub the nose.
Avoid leaning backwards during nosebleed due to possible choking of blood.