| Course | NRNP 6537 Adult Acute Care: Comprehensive Patient Management I |
|---|---|
| Week | Week 5 |
| Paper type | SOAP note |
| Length | About 1,060 words, 6 pages |
| Format | APA 7 student paper |
| School | Walden University |
| Program | MSN Adult-Gerontology Acute Care Nurse Practitioner (AGACNP) |
| Updated | October 2026 |
Free sample paper for NRNP 6537 Week 5
SOAP Note: Syncope Nine Days After Knee Replacement in a 62-Year-Old Woman Without Anticoagulation
Student Name
College of Nursing, Walden University
NRNP 6537: Advanced Nurse Practice in Adult/Gerontology Acute Care I
Instructor Name
Month Day, Year
SOAP Note: Syncope Nine Days After Knee Replacement in a 62-Year-Old Woman Without Anticoagulation
Subjective (triage 14:05)
Chief complaint: "I passed out in my kitchen."
History of present illness: P.G., a composite 62-year-old retired bookkeeper, had a right total knee replacement nine days ago. She was discharged on day three with a two-week course of an oral anticoagulant for thromboprophylaxis but stopped it on day five because of bruising at the incision, without telling anyone. Today at about 13:15, while standing at her kitchen counter, she became suddenly short of breath, felt her heart racing, and collapsed; her husband found her on the floor, and she was awake within a minute. She has had a dull ache in the right calf for two days, which she assumed was from physical therapy. She reports ongoing breathlessness and a sharp pain in the left chest that worsens with deep breaths.
Pertinent negatives for syncope: no preceding warmth, nausea, or tunnel vision that would suggest a vasovagal episode; no exertional chest pressure beforehand; no tongue biting, incontinence, or confusion after waking that would suggest seizure; no melena, vomiting, or poor intake that would suggest hypovolemia; no prior syncope, known arrhythmia, or family history of sudden death. No head strike reported.
Medications: acetaminophen and an oral opioid for postoperative pain; lisinopril for hypertension. No hormone therapy.
Objective (14:15 to 15:40)
Perfusion: heart rate 124 and regular, blood pressure 104/66 lying and 92/60 sitting, capillary refill three seconds, skin cool at the extremities. Mental status normal.
Oxygenation: respiratory rate 26, saturation 89 percent breathing room air and 95 percent once 4 L/min of oxygen was added by cannula. Lungs clear with a faint left pleural rub.
The legs: right calf swollen, with a circumference 3.5 cm greater than the left measured 10 cm below the tibial tuberosity, tender along the deep veins; knee incision clean and dry.
The right heart: jugular venous pressure elevated; a loud pulmonic component of the second heart sound. Electrocardiogram: sinus tachycardia with a new right bundle branch block and T-wave inversions in V1 to V3.
Laboratory: troponin mildly elevated; B-type natriuretic peptide elevated; creatinine normal; hemoglobin stable from discharge.
Assessment
Pretest probability is set before any imaging. Applying the Wells criteria: clinical signs of deep vein thrombosis, an alternative diagnosis less likely than pulmonary embolism, heart rate above 100, and surgery within the past four weeks, giving a score well above the threshold at which pulmonary embolism is considered likely (Wells et al., 2000). The PERC rule was not applied, because it is designed only to exclude embolism in patients already judged to be at low clinical probability, and she is at high probability; using it here would be a misuse of the tool (Kline et al., 2004). Nor would a D-dimer help: in a high-probability patient a negative result would not safely exclude embolism, and after surgery it is expected to be elevated.
1. Pulmonary embolism with right ventricular strain. For: recent major orthopedic surgery, stopped prophylaxis, unilateral calf swelling, sudden dyspnea with syncope, pleuritic pain, hypoxemia, tachycardia, borderline blood pressure, and electrocardiographic and biomarker evidence of right ventricular strain. Syncope in this setting suggests a large embolic burden.
2. Arrhythmic syncope. For: syncope with palpitations. Against: a sinus rhythm on the monitor throughout, and the syncope is better explained by a sudden fall in cardiac output from embolism.
3. Hypovolemia or postoperative bleeding. For: borderline blood pressure after surgery. Against: stable hemoglobin, no bleeding source, and elevated rather than low jugular venous pressure.
Plan
Imaging: computed tomographic pulmonary angiography is the test of choice, since she has normal kidney function and is stable enough to travel with monitoring; multidetector angiography has high diagnostic accuracy for pulmonary embolism, particularly when combined with clinical probability (Stein et al., 2006). It confirmed bilateral pulmonary emboli with an enlarged right ventricle relative to the left.
Risk stratification after a positive result: she is not in shock and has maintained her blood pressure without support, so she is not high risk. But she has both imaging evidence of right ventricular dysfunction and elevated cardiac biomarkers, placing her in the intermediate-high risk group, which carries a real risk of deterioration in the first days.
Treatment: therapeutic anticoagulation started in the emergency department once imaging confirmed the diagnosis, with a parenteral agent chosen so that it can be stopped or adjusted quickly if she deteriorates. Systemic thrombolysis is not given now because she is hemodynamically stable and nine days after major surgery raises her bleeding risk; it would be reconsidered, along with catheter-directed options, if she develops hypotension.
Disposition: she goes to the intensive care unit or a monitored step-down bed for at least the first 48 hours, given her intermediate-high risk. Findings that would trigger escalation: falling blood pressure, rising oxygen requirement, worsening tachycardia, or new confusion. The surgical team was informed, and the reason she stopped prophylaxis will be addressed in discharge teaching.
Why Not Another Test First
Three alternatives were considered and set aside. A ventilation-perfusion scan avoids contrast and is useful when kidney function is poor or contrast allergy is present, but her kidneys are normal, and angiography also shows the right ventricle and alternative diagnoses. A bedside compression ultrasound of the right leg would likely show a deep vein thrombosis, and in a patient too unstable for transport a positive leg study with right ventricular strain on echocardiography can justify treatment; she was stable enough for angiography, which answers the question directly. A bedside echocardiogram was performed while awaiting the scanner and showed a dilated right ventricle, which supported urgency but does not confirm embolism on its own. The sequence mattered: probability first, then the test that could answer the question and stratify risk at the same time.
Timeline Summary and Communication
Key times: arrival and triage 14:05; examination, electrocardiogram, and pretest probability documented by 14:30; bedside echocardiogram 14:50; angiography 15:25; diagnosis confirmed and anticoagulation started 15:40; accepted by the intensive care team 16:10. Her husband was told that clots had traveled from her leg to her lungs, that her heart is under strain but her blood pressure is holding, and that she will be watched closely because the first days carry the most risk. She was told, without blame, that stopping the blood thinner early likely contributed, and that bruising is a reason to call rather than to stop.
References
Kline, J. A., Mitchell, A. M., Kabrhel, C., Richman, P. B., & Courtney, D. M. (2004). Clinical criteria to prevent unnecessary diagnostic testing in emergency department patients with suspected pulmonary embolism. Journal of Thrombosis and Haemostasis, 2(8), 1247-1255. https://doi.org/10.1111/j.1538-7836.2004.00790.x
Stein, P. D., Fowler, S. E., Goodman, L. R., Gottschalk, A., Hales, C. A., Hull, R. D., Leeper, K. V., Jr., Popovich, J., Jr., Quinn, D. A., Sos, T. A., Sostman, H. D., Tapson, V. F., Wakefield, T. W., Weg, J. G., & Woodard, P. K. (2006). Multidetector computed tomography for acute pulmonary embolism. New England Journal of Medicine, 354(22), 2317-2327. https://doi.org/10.1056/NEJMoa052367
Wells, P. S., Anderson, D. R., Rodger, M., Ginsberg, J. S., Kearon, C., Gent, M., Turpie, A. G. G., Bormanis, J., Weitz, J., Chamberlain, M., Bowie, D., Barnes, D., & Hirsh, J. (2000). Derivation of a simple clinical model to categorize patients probability of pulmonary embolism: Increasing the models utility with the SimpliRED D-dimer. Thrombosis and Haemostasis, 83(3), 416-420. https://doi.org/10.1055/s-0037-1613830
The Walden NRNP 6537 Week 5 instructions
In Week 5, NRNP 6537 often asks for a SOAP note on an acute presentation where a decision rule guides testing. You document a timed history and examination, estimate pretest probability with a validated tool, choose tests accordingly, interpret results, classify risk and plan management. Faculty look for the probability step before imaging. NRNP 6537 notes of this kind run a few pages, with the ESC guidance cited in APA 7. A few NRNP 6537 sections want rules you set aside, such as PERC, explained too, so the grader sees they were weighed. Anticoagulant choice and dosing may be left out so the focus stays on diagnosis. Communication and timeline summaries are often part of the grade. NRNP 6537 faculty want the Wells score shown item by item so the total can be checked. State how right ventricular strain was assessed, whether by CT, echocardiogram or biomarkers. Name the risk class that results and what it means for disposition.
How the NRNP 6537 Week 5 example is put together
A full SOAP note of about five pages, time-stamped from triage. In the subjective section sit the collapse, the recent surgery and the absence of anticoagulation, alongside the pertinent negatives a syncope workup demands. Objective findings are grouped by what they bear on: perfusion, oxygenation, the legs and the right heart. In the assessment, the Wells criteria set a pretest probability before any imaging is discussed, and a sentence explains why the PERC rule was not applied, since it is meant only for patients already judged low probability. The differential ranks embolism first, then arrhythmic syncope and hypovolemia, each moved by a named finding. The plan defends the imaging choice, the risk stratification that followed a positive result, and the level of care, with dosing left entirely out.
Reading the NRNP 6537 Week 5 rubric
Probability reasoning collects the largest share in this note. A SOAP note that orders imaging on every breathless patient without stating a pretest probability has skipped the step the Wells criteria exist to formalize, and graders reading for clinical reasoning notice the gap at once. Misapplied decision rules are the second recurring loss, most often PERC used to dismiss embolism in a patient who was never low probability to begin with. Third, the disposition is frequently asserted rather than argued, so the reader cannot see what risk stratification contributed. Vital signs quoted one way in the objective section and another way in the assessment draw deductions of their own. Notes missing the pertinent negatives for syncope lose smaller amounts throughout, because the assessment then rests on findings nobody checked.
Common NRNP 6537 Week 5 mistakes, and how to avoid them
Notes on suspected embolism lose the most when imaging is ordered on every breathless patient without a stated pretest probability. Calculate it and say what it means for testing. Another common error is ordering a D-dimer in a high-probability patient, where a negative result cannot rule out embolism. Writers also skip risk classification after diagnosis, though right ventricular strain changes management. Assess it. Avoid ignoring syncope as a severity marker. Keep times consistent through the note. Explain why PERC does not apply. Close with who was told and when. Students also forget to record why she had no anticoagulation after surgery, which matters for prevention later. Ask and note it. Another frequent gap is skipping the ECG findings or describing them vaguely. Report them. Keep the timeline summary to key events.
Get a NRNP 6537 Week 5 example written to your instructions
A pulmonary embolism SOAP example written to your frame, triage through disposition, follows once the Week 5 prompt, rubric and any supplied case findings reach the desk. It costs nothing on a first request and is ready within 24-48h, with each decision rule applied only inside its intended scope.
More NRNP 6537 papers and AGACNP samples
- NRNP 6537 Week 1: AGACNP Scope Discussion
- NRNP 6537 Week 2: Unstable Tachycardia Case
- NRNP 6537 Week 3: Respiratory Failure Note
- NRNP 6537 Week 4: Septic Shock Case
- NRNP 6537 Week 6: DKA management note
- NRNP 6537 Week 7: Acute liver failure escalation thread
- NRNP 6537 Week 8: Acute stroke pathway write-up
- NRNP 6537 Week 9: Multisystem ICU progress note
- NRNP 6537 Week 10: Acute hyperthermia capstone case
- NRNP 6537 Week 11: Acute care judgment reflection
- NRNP 6539 Week 5: CKD and gout SOAP note
- NRNP 6531 Week 5: Dysuria Visit Note
- NRNP 6540 Week 5: Atypical presentation geriatric note
- NRNP 6831 Week 5: Access and resource analysis
NRNP 6537 Week 5 questions, answered
Why explain a rule the note did not use?
Because using the wrong rule is one of the most common errors in embolism write-ups, and naming why PERC was set aside shows the author knows its scope. The rule was designed for patients already judged low probability, and this patient was not. One sentence makes that visible, and it usually outscores a paragraph that recites the criteria.
Does the plan include anticoagulant choice or dosing?
It discusses anticoagulation only as a decision that follows risk stratification and bleeding risk, without naming a drug regimen or dose. Those belong to the prescriber and current guidance. The sample's contribution is the sequence of reasoning from probability to disposition, which is where the midcourse SOAP rubric concentrates its reading.
Can the SOAP note use a patient from my own unit?
The example uses an invented patient, and a classroom SOAP note is safer built the same way: generalize the demographics, drop dates and unit names, and keep only the clinical pattern. Where faculty hand out a case, send it and the note is written to those findings instead. Nothing from your own practice is reconstructed on this side.
Where can I find a free NRNP 6537 Week 5 sample paper?
The post-operative syncope note is reproduced here with the Wells score, the testing choice, the risk classification and the timeline summary.
Why skip the D-dimer in NRNP 6537 Week 5?
The patient's Wells score put her at high probability, so a negative D-dimer could not rule out embolism. The example goes straight to CT pulmonary angiography.