SOAP Note
10/28/15 1450-----------------------------------------------------------------------------------------------------------------------S: Patient stated pain at a #2/10 after receiving pain medication one hour prior to procedure. Patient verbalized consent and understanding of procedure. Patient stated that laying on his stomach relieved his pain.-----------------------------------------------------------------------------------------------------------------------------O: 40 y.o. Caucasian male. General: well-groomed, pleasant male. Patient had stage four pressure ulcer on sacrum. Removed wound dressing. There was 5% of thin serosanguineous drainage on ABD dressing. There was 20% of thin serosanguineous drainage on 4x4s. There was 50%of thin serosanguineous drainage on the kerlix super sponges. No unusual odor noted. Irrigated wound with NS, fluid returned clear. Obtained wound culture, sent to lab. Wound measured 10cm x 7.7cm. In the wound bed there was slough from 11 o’clock to 1 o’clock position and from 4 o’clock to 5 o’clock position. Slough making up 20% of wound bed. 80% of wound bed was granulation tissue. Bone was showing in the middle of wound. No redness or edema noted. No ecchymosis noted. Wound not approximated. Applied sterile wet-to-dry dressing. Patient tolerated procedure well. No signs of facial grimacing or guarding during procedure. -------------------------------------------------------------------------------------------------------------------------A: Impaired skin integrity related to physical immobility as evidenced by stage four pressure ulcer on sacrum. ------------------------------------------------------------------------------------------------------------------------------P: The nurse will reposition patient q2h to prevent further skin breakdown. The nurse will assess the wound daily for redness, swelling, warmth, pain and