NURS 210 Week 3 SOAP Note Example

SOAP Note: Face, Head and Neck Examination of an Adult Volunteer With Recurrent Tension-Type Headaches

S: Subjective

Client: Ms. R., 52-year-old woman, consenting adult volunteer.

Reason for examination: course assignment; client reports recurring headaches and asked whether anything in her head or neck "looks wrong."

History of present concern: Headaches began about two years ago, occurring about twice a month, usually late in the workday at the end of the month. She describes them as "a tight band around my forehead and the back of my head," both sides, rating them 4 out of 10 at worst. They last two to four hours. Ibuprofen 400 mg relieves them within an hour. She denies visual changes, nausea, vomiting, sensitivity to light, numbness or weakness with the headaches and denies the "worst headache of my life." Stress and missed lunch make them worse; walking and sleep make them better. She reports some jaw tightness in the morning and says her husband has heard her grind her teeth.

Relevant history: seasonal allergic rhinitis; borderline blood pressure reading at a pharmacy kiosk; family history of hypertension and stroke. Medications: loratadine 10 mg daily in season, ibuprofen 400 mg as needed about twice a month. Allergies: penicillin (rash). Last dental visit four months ago.

Client goal in her words: "I'd like to get fewer headaches without taking more pills."

O: Objective

Vital signs: temperature 98.2 °F oral; pulse 74, regular; respirations 16, unlabored; blood pressure 134/84 right arm and 132/82 left arm, seated, after five minutes' rest; oxygen saturation 98% on room air. She rated her pain as 0 of 10 during the visit.

Head: normocephalic and symmetric. Scalp intact without lesions, scaling or tenderness. Hair evenly distributed. Temporal arteries soft, nontender, pulses palpable bilaterally.

Face: symmetric at rest and with movement. No edema, lesions or involuntary movements. Frontal and maxillary sinuses nontender to palpation.

Cranial nerve V (trigeminal): light touch sensation intact over forehead, cheeks and jaw bilaterally; masseter and temporalis muscles contract equally when client clenches teeth. Mild tenderness to palpation over both masseter muscles.

Cranial nerve VII (facial): raises eyebrows, closes eyes against resistance, smiles, puffs cheeks and frowns symmetrically.

Temporomandibular joints: full range of motion; opening to three fingerbreadths; soft click palpated on the right with opening, without pain or locking.

Neck: moves her head forward, back, side to side and ear toward shoulder through a full range, pain-free. Mild tightness and tenderness along both upper trapezius muscles. No masses or visible pulsations.

Trachea: midline.

Thyroid: palpated from behind with the client swallowing water; gland smooth, nontender, without nodules or enlargement.

Carotid arteries: each side palpated separately, never both together; pulses 2+ and equal; no bruits heard with the bell.

Lymph nodes: none palpable on either side. Checked in order: in front of and behind the ears and at the base of the skull (preauricular, posterior auricular, occipital); along and under the jaw and chin (tonsillar, submandibular, submental); down the neck in front of, over and behind the sternocleidomastoid (superficial cervical, deep cervical chain, posterior cervical); and above the clavicles (supraclavicular).

D'Amico and Barbarito (2016) describe palpating the lymph nodes in a consistent sequence with the pads of the fingers in gentle circular motions, comparing sides, which is the method used here.

A: Assessment

Nursing diagnosis: Readiness for enhanced health self-management, as evidenced by the client's expressed desire to reduce headaches "without taking more pills" and her desire to manage the stress and missed meals she identifies as triggers (Herdman et al., 2024).

Supporting data: recurring bilateral, band-like headaches associated with work stress and skipped meals; morning jaw tightness and reported teeth grinding; tenderness over the masseter and upper trapezius muscles; normal neurological findings of cranial nerves V and VII; no red-flag features reported, such as sudden severe onset, visual change or weakness; blood pressure in the borderline range on two readings.

Rationale: The client has no current pain and no evidence of a problem requiring a deficit-focused diagnosis such as acute pain. Her clearly stated wish to manage her health differently, and her ability to name her own triggers, match a health-promotion diagnosis. The NANDA-I classification describes readiness diagnoses as patterns that can be strengthened when the client expresses a desire to enhance them (Herdman et al., 2024).

Findings to Watch

Several findings would change this assessment if they appeared later. A headache that becomes sudden and severe, wakes her from sleep, worsens with lying down or comes with fever, stiff neck, vision loss, weakness or confusion would no longer fit the pattern she describes and would need prompt medical evaluation. New enlargement of a lymph node, a thyroid nodule or a carotid bruit would also call for referral. Her blood pressure readings, which are above the normal range on both arms today, are not a diagnosis on their own, but they add weight to her family history of hypertension and stroke and are the main reason the plan includes a primary care follow-up. Nothing in today's examination suggests that her headaches come from a structural problem in the head or neck; the muscle tenderness and jaw findings fit the stress and teeth-grinding she reports.

P: Plan

Goal: Within six weeks, the client will report no more than one headache per month and will have used ibuprofen no more than twice in that period, as recorded in a headache diary.

Interventions and teaching:

• 1. Teach the client to keep a headache diary recording date, time, severity, possible triggers, meals and medication taken, and review it at follow-up.
• 2. Discuss practical changes for her identified triggers: a planned lunch break at work and a small afternoon snack on deadline days.
• 3. Teach simple neck and shoulder stretches and relaxation breathing for use at her desk, demonstrated with return demonstration.
• 4. Encourage her to mention the jaw tightness and grinding to her dentist, who may recommend a night guard.
• 5. Because her blood pressure was 134/84 and 132/82, measured with the seated, rested technique the American Heart Association recommends (Muntner et al., 2019), teach her to have her blood pressure checked by her primary care provider and to bring her kiosk and home readings, without labeling her as having hypertension.
• 6. Teach warning signs that require prompt care: a sudden, severe headache, headache with weakness, confusion, vision loss or stiff neck with fever.

Evaluation: Review the diary and blood pressure follow-up at a check-in in six weeks; revise the plan if headaches have not decreased. The note documents a normal examination and still finds something useful to do, because the client told us what she wanted.

References

D'Amico, D., & Barbarito, C. (2016). Health and physical assessment in nursing (3rd ed.). Pearson.

Herdman, T. H., Kamitsuru, S., & Lopes, C. T. (Eds.). (2024). NANDA International nursing diagnoses: Definitions and classification, 2024-2026 (13th ed.). Thieme.

Muntner, P., Shimbo, D., Carey, R. M., Charleston, J. B., Gaillard, T., Misra, S., Myers, M. G., Ogedegbe, G., Schwartz, J. E., Townsend, R. R., Urbina, E. M., Viera, A. J., White, W. B., & Wright, J. T. (2019). Measurement of blood pressure in humans: A scientific statement from the American Heart Association. Hypertension, 73(5), e35-e66. https://doi.org/10.1161/HYP.0000000000000087