soap notes & fluid restrictions

I did a Pt R/A in SAR unit and conducted meal rounds on 5 Pts to supplement their f/u notes. Afterwards, I did a Pt interview and discussed any difficulties feeding, swallowing, or chewing, and any c/o N/V/D/C. The Pt had no current complaints. It’s great to practice talking to Pts and be more comfortable! Afterwards, I formulated a nutrition note (SOAP note) for the first time today, and it was a success! I need more practice though, but I’ll be an expert in no time. It was also kind of fun writing the note- the whole nutrition assessment actually! It’s a nice puzzle to get the hang of and get your brain working. I learned that people’s perceptions of how much a Pt eats differs- therefore, taking pictures of their completed meal tray or going on meal rounds as much as possible would be a good idea. I also learned that elevated glucose levels can be d/t acute stress if a Pt doesn’t have any issues directly r/t glucose. At the end of the day, we talked about fluid retention, and that the MD or nephrologist decides how much fluid to restrict. The information is then communicated to dietary and nursing staff to monitor the Pts’ fluid intake. 4 oz is approximately 120 mL and 8 oz is approximately 240 mL. Today was a good day, and I’m looking forward to banging out this nutrition counseling tomorrow! Hopefully I do ok.

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