Nursing Assignment, SOAP note on sickle cell crisis

Chief complaint : A 4 year old came in with generalized pain x 2 days

Write on the past history illness in this order:
Location
Quality
Quality or severity
Timing including onset, duration and frequency
Setting in which it occurs
Factors that have aggravated or relieved the symptoms
Associated manifestations.

Medications: list each one by name with dosage and frequency.

Past medical history: include illness , hospitalization,childhood illness.

Assessment: need to list priority diagnosis first. For each priority diagnosis, list at least three differential diagnosis. Support your selection with evidence.
For example: Migraine headache (tension headache, cluster headache, brain tumor).

For holistic care you need to write on sickle cell crisis and indicate whether these are controlled or not controlled and remember to include that in your treatment plan.

What evidence or national treatment guidelines did you use to support your diagnoses?.
PLAN: treatment plan. Lab , X-ray etc include both pharmacological and no pharmacological strategies. Include alternative therapies. When do they need to follow up? Any referrals? Consultation?

Health promotion: what does the family need to do to promote their health? Exercise, healthy diet , safety etc
Disease prevention: for the patient age , what need to be done to detect disease early…..fasting lipid profile, immunization etc….

What evidence (eg national treatment guidelines) did you use to support your treatment plan?

Reflection: what did you learn from this experience? What would you do differently? Do you agree with your preceptor based on the evidence?