Psychiatric Nursing SOAP Note Example

Below is a psychiatric nursing SOAP note based on a case study, incorporating all applicable components and subcomponents, and utilizing the OLDCART acronym in the History of Present Illness (HPI) section:

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Subjective:

1. Chief Complaint: Patient reports feeling anxious and having difficulty sleeping.
2. HPI (History of Present Illness):
   • Onset: The patient states that the symptoms started approximately six months ago.
   • Location: The patient reports experiencing the symptoms predominantly in their mood, cognition, and sleep patterns.
   • Duration: The patient mentions that the symptoms have been persistent since their onset.
   • Character: The patient describes the anxiety as a sense of worry, restlessness, and racing thoughts. They mention having difficulty falling asleep and feeling on edge.
   • Aggravating Factors: The patient reports that the symptoms worsen in crowded places, during social interactions, and when anticipating important events.
   • Relieving Factors: The patient states that engaging in deep breathing exercises and practicing mindfulness techniques provide temporary relief.
   • Treatment/Interventions Tried: The patient mentions that they have tried self-help books and online resources for anxiety management.
3. Past Psychiatric History: The patient reports a previous diagnosis of generalized anxiety disorder (GAD) three years ago. They underwent therapy and took prescribed medications for approximately six months. The patient reports some improvement in symptoms but discontinued treatment after feeling better.
4. Family Psychiatric History: The patient’s father has a history of depression and anxiety disorder, while their mother has no reported psychiatric conditions.
5. Social History: The patient is currently employed part-time as a teacher. They report having a supportive network of friends and family. The patient mentions recent stressors related to work demands and personal relationships.
6. Substance Use History: The patient denies any history of substance abuse or dependence.
7. Medical History: The patient has a history of migraines and occasional episodes of acid reflux. They have no significant medical conditions or chronic illnesses.
8. Medication History: The patient is not currently taking any medications.
9. Allergy History: The patient reports no known allergies to medications, foods, or environmental factors.

Objective:

1. Vital Signs: Blood pressure: 120/80 mmHg, Heart rate: 80 bpm, Respiratory rate: 16 breaths per minute, Temperature: 36.7°C.
2. Physical Examination Findings: No abnormal findings during the physical examination.
3. Laboratory and Diagnostic Test Results: None.
4. Objective Observations: The patient appears restless and exhibits fidgeting behaviors during the session. They display signs of anxiety, including a tense facial expression, rapid speech, and increased psychomotor activity.

Assessment:

1. Nursing Diagnoses:
   • Generalized Anxiety Disorder related to excessive worry and restlessness.
   • Ineffective Coping related to difficulty managing anxiety symptoms.
2. Problem Identification: Patient reports excessive worry, restlessness, racing thoughts, difficulty falling asleep, and feeling on edge.
3. Risk Factors: Patient history of GAD, recent stressors, lack of consistent treatment adherence.
4. Client Strengths and Resources: Patient has a supportive network of friends and family, previous knowledge of anxiety management techniques.
5. Relevant Findings and Abnormalities: Patient exhibits signs of anxiety, including fidgeting, tense facial expression, and rapid speech.
6. Psychosocial Assessment: Patient expresses feelings of overwhelm, increased stress, and difficulty managing daily tasks. Reports reduced enjoyment in previously pleasurable activities.
7. Client Education Needs: Patient requires education on coping strategies, stress reduction techniques, and the importance of treatment adherence.

Plan:

1. Nursing Interventions:
   • Teach deep breathing exercises and relaxation techniques to manage anxiety symptoms.
   • Collaborate with the healthcare provider to initiate pharmacological treatment for anxiety as prescribed.
   • Assist the patient in identifying triggers and developing coping strategies to manage anxiety in social situations.
   • Provide therapeutic communication and active listening to promote emotional support.
   • Schedule regular follow-up sessions to monitor progress and evaluate response to treatment.
2. Collaborative Interventions:
   • Refer the patient to a licensed mental health professional for ongoing therapy and counseling.
   • Consult with the healthcare provider for medication evaluation and management.
3. Patient Education:
   • Educate patient on the benefits and potential side effects of prescribed medications.
   • Provide information on relaxation techniques, cognitive-behavioral strategies, and self-care activities to manage anxiety.
4. Safety Measures:
   • Assess the patient’s safety and implement a safety plan if there are any indications of self-harm or suicidal ideation.
   • Provide crisis hotline contact information and emergency resources.
5. Referrals or Consultations:
   • Refer the patient to a support group for individuals with anxiety disorders.
   • Consult with a social worker to explore available community resources for ongoing support.
6. Evaluation:
   • Monitor patient’s anxiety symptoms, sleep patterns, and overall functioning regularly.
   • Assess patient’s response to medication and therapy interventions.
   • Re-evaluate nursing diagnoses and adjust the plan of care as needed.

• This example demonstrates a psychiatric SOAP note based on a case study, incorporating all applicable components and subcomponents.
• It provides a comprehensive assessment of the patient’s mental health, including their history of anxiety, presenting symptoms, psychosocial factors, and nursing diagnoses.
• The plan outlines the nursing interventions, collaborative actions, patient education, safety measures, and referrals necessary to address the patient’s needs and promote their well-being.