What is an example of a brief SOAP note for follow-up evaluation for wound care rounds on an elderly patient with diabetes and peripheral vascular disease, presenting with a stage III pressure ulcer in a skilled nursing facility?

SOAP Note Example for Wound Care Follow-Up in Skilled Nursing Facility

A comprehensive SOAP note for wound care rounds in a skilled nursing facility should systematically document assessment findings, clinical reasoning, and treatment modifications while addressing infection risk, perfusion status, and healing progress.

Subjective

• Pain assessment: Document current pain level (0-10 scale), character, and timing relative to dressing changes 1
• Functional status changes: Note any new confusion, depression, or refusal of care that may interfere with wound management 1
• Dietary intake: Record percentage of meals consumed, as intake <75% requires intervention in diabetic patients with wounds 1
• New symptoms: Document fever, chills, increased wound drainage, or worsening odor suggesting infection 1

Objective

Vital Signs and Systemic Assessment

• Temperature, heart rate, blood pressure: Fever and tachycardia may indicate systemic infection, though these signs are frequently absent in elderly nursing home residents 1
• Mental status: Document any acute changes, as delirium may be the only sign of infection in this population 1

Wound Assessment

• Location and measurements: Record length × width × depth in centimeters; photograph if available 1
• Wound bed characteristics: Describe percentage of granulation tissue, slough, eschar, or necrotic tissue requiring debridement 1, 2
• Periwound skin: Document erythema (measure distance from wound edge), warmth, induration, or maceration 1
• Drainage: Quantify amount (scant/moderate/copious) and describe character (serous/serosanguinous/purulent) 1
• Odor: Note presence and severity, as foul odor suggests anaerobic infection 1

Perfusion Assessment (Critical for Diabetic/Vascular Wounds)

• Pedal pulses: Palpate dorsalis pedis and posterior tibial pulses bilaterally 2, 3
• Capillary refill: Document if >3 seconds, indicating poor perfusion 3
• Skin temperature and color: Note coolness, pallor on elevation, or rubor on dependency 3, 4
• Ankle-brachial index (ABI) or toe pressures: If available, document values; ABI <0.5, toe pressure <30 mmHg, or TcPO2 <25 mmHg requires urgent vascular consultation 2, 3, 4

Infection Assessment

• Clinical signs: Purulent drainage, erythema extending >2 cm from wound edge, increased warmth, increased pain, or exposed bone (probe-to-bone test) 1
• Laboratory values: White blood cell count, C-reactive protein if obtained 1
• Culture results: Document if deep tissue cultures were obtained (preferred over swabs) 1

Diabetes-Specific Assessment (if applicable)

• Recent glucose values: Document fasting and postprandial readings; hyperglycemia impairs healing 1, 3
• Neuropathy assessment: Test protective sensation with monofilament 1
• Pressure assessment: Note if offloading device is in use and effective 1, 2

Assessment

Primary Diagnosis

• Stage of pressure ulcer (I-IV) or type of ulcer (diabetic neuropathic, arterial, venous) with anatomic location 1

Healing Status

• Improving: Decreasing size, increasing granulation tissue, decreasing drainage 1
• Static: No change in 2-4 weeks despite appropriate treatment; requires reassessment 1, 2
• Deteriorating: Increasing size, necrotic tissue, signs of infection 1

Complications

• Infection: Classify as superficial soft tissue infection vs. deep infection vs. osteomyelitis 1, 3
• Ischemia: Document if perfusion is adequate for healing or if revascularization needed 2, 3
• Malnutrition: Note if patient is at risk based on poor intake or weight loss 1

Barriers to Healing

• Cognitive dysfunction: Refusal of dressing changes or glucose monitoring 1
• Physical disability: Inability to offload pressure or perform repositioning 1
• Depression: Poor dietary intake or lack of engagement in care 1

Plan

Wound Care Modifications

• Debridement: Sharp surgical debridement of necrotic tissue if present; repeat as needed 1, 2, 3
• Dressing selection: Choose based on exudate level and wound bed characteristics (e.g., foam for moderate exudate, hydrogel for dry wounds, alginate for heavy exudate) 1, 5
• Frequency: Specify dressing change schedule (daily, every 2-3 days, weekly) 1

Infection Management

• Topical antimicrobials: Consider if superficial infection with no systemic signs 1
• Systemic antibiotics: Initiate broad-spectrum coverage if clinical infection present; adjust based on culture results 1, 3
• Surgical consultation: Urgent referral if deep infection, exposed bone, or crepitus 1, 3

Perfusion Optimization

• Vascular consultation: Urgent if ABI <0.5, toe pressure <30 mmHg, or non-healing ischemic ulcer 2, 3, 4
• Cardiovascular risk reduction: Ensure statin therapy, antiplatelet agent (aspirin or clopidogrel), blood pressure control, and smoking cessation support 2, 3

Pressure Offloading (for pressure ulcers and diabetic foot ulcers)

• Repositioning schedule: Every 2 hours for immobile patients 1
• Pressure-relieving devices: Specialty mattress, heel protectors, or offloading footwear 1, 2
• Activity modifications: Non-weight-bearing status if plantar ulcer 1

Nutritional Optimization

• Dietary modifications: Offer regular diet with preferred foods; provide substitutions if intake <75% 1
• Protein supplementation: High-protein oral nutritional supplements (especially formulas with arginine, zinc, antioxidants) for malnourished patients 1, 4
• Nutrition consultation: If continued poor intake or weight loss 1

Diabetes Management (if applicable)

• Glucose control: Target <140 mg/dL; adjust insulin to match carbohydrate intake 1, 3
• Insulin timing: Administer prandial insulin immediately after meals to avoid hypoglycemia in patients with variable intake 1
• Glucose monitoring: Increase frequency during acute illness or infection 1

Advanced Wound Therapy (if non-healing after 4 weeks)

• Criteria: Consider if wound fails to show 50% reduction in size after 4 weeks of appropriate standard care 1
• Options: Negative-pressure wound therapy, bioengineered skin substitutes, platelet-derived growth factor, or acellular matrix products 1, 4

Follow-Up Schedule

• Frequency: Weekly for healing wounds; more frequent (2-3 times weekly) for infected or deteriorating wounds 1
• Reassessment triggers: No improvement in 4-6 weeks, new signs of infection, or clinical deterioration 1, 2, 4

Documentation

• Photography: Weekly or with significant changes 1
• Measurements: Weekly length × width × depth 1
• Communication: Notify physician if signs of infection, ischemia, or non-healing 1, 3

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Common Pitfalls to Avoid:

• Never delay vascular consultation in diabetic patients with foot ulcers and signs of peripheral arterial disease—this combination is a surgical emergency requiring intervention within hours 2, 3
• Do not rely on ABI alone in diabetic patients due to arterial calcification causing falsely elevated readings; always obtain toe pressures 2, 3, 6
• Avoid superficial swab cultures for suspected deep infection; obtain deep tissue specimens or aspirates after irrigation 1
• Do not continue "no concentrated sweets" diets, as these are ineffective for glycemic control and may worsen malnutrition; offer regular diet with consistent carbohydrates 1
• Never assume absence of fever or leukocytosis rules out infection in elderly nursing home residents, as systemic signs are frequently absent 1