| Course | NURS 3025 Health Assessment |
|---|---|
| Week | Week 9 |
| Paper type | Focused SOAP note |
| Length | About 550 words, 4 pages |
| Format | APA 7 student paper |
| School | Walden University |
| Program | Bachelor of Science in Nursing (BSN) |
| Updated | October 2026 |
Free sample paper for NURS 3025 Week 9
Focused SOAP Note: Two Days of Right Ear Pain in a 4-Year-Old, With the Parent as Historian
Student Name
College of Nursing, Walden University
NURS 3025: Health Assessment
Instructor Name
Month Day, Year
Focused SOAP Note: Two Days of Right Ear Pain in a 4-Year-Old, With the Parent as Historian
Subjective
Historian: mother, who states she is with the child daily and was present when symptoms began; reliable. Chief concern, as stated by the mother: "She's been pulling at her right ear and crying at night for two days." History of present illness: ear pulling and crying began 2 days ago, 1 day after a runny nose started. Mother measured a temperature of 101.2 degrees Fahrenheit at home last night; gave children's ibuprofen at the dose on the package, with relief for about 5 hours. Child told her mother, "My ear hurts." Mother reports reduced appetite but normal fluid intake and four wet diapers or toilet voids a day. Denies ear drainage, vomiting, rash, or trouble breathing. Past history: two ear infections before age 2; full-term birth; immunizations up to date per mother's record, including the pneumococcal series. Attends preschool 5 days a week. No one smokes at home. Development, per mother: speaks in full sentences strangers can understand, hops on one foot, draws a person with several body parts, dresses herself with help for buttons.
Objective
Temperature 100.9 degrees Fahrenheit, temporal. Heart rate 118, respiratory rate 24, oxygen saturation 99% on room air. Weight 16.5 kg, 50th percentile; height 103 cm, 50th percentile on the CDC growth chart for girls; both consistent with her previous visits.
Behavior during examination: clung to her mother at first, then allowed the stethoscope after being shown it on a stuffed animal; cried and turned her head away when the right ear was approached; calm again within a minute on her mother's lap. Counted as a finding: the reaction was specific to the right ear.
Ears, examined with the child on her mother's lap: right ear canal clear; right tympanic membrane red, full, and moderately bulging, landmarks not visible, no perforation, no drainage. Left ear canal clear; left tympanic membrane pearly gray, translucent, landmarks visible, light reflex present. Nose: clear drainage from both nostrils. Throat: mildly red, tonsils 1+, no exudate. Neck: small, mobile, nontender lymph nodes on both sides. Lungs: clear throughout. Heart: regular, no murmur. Skin: no rash.
Assessment
Findings consistent with acute otitis media of the right ear: a moderately bulging right eardrum with recent onset of ear pain, which meets the guideline's diagnostic definition (Lieberthal et al., 2013). No severe signs: pain less than 48 hours, temperature below 102.2 degrees Fahrenheit, child not toxic-appearing. Growth steady at the 50th percentile. Development consistent with expected milestones for a 4-year-old (Zubler et al., 2022).
Plan
Reported to the provider, who discussed options with the mother: for a child older than 2 without severe signs, the guideline permits either antibiotics or observation with follow-up, provided the family can be reached and can return (Lieberthal et al., 2013). The mother chose observation with a safety-net prescription to fill if symptoms do not improve. Pain relief with ibuprofen at a weight-based dose. Mother taught, and repeated back, the signs to return or call: pain or fever continuing after 48 to 72 hours, temperature at or above 102.2 degrees Fahrenheit, ear drainage, swelling behind the ear, or unusual sleepiness. Follow-up phone call in 48 hours. Growth and development recorded for her next well-child visit (Bickley et al., 2021).
References
Bickley, L. S., Szilagyi, P. G., Hoffman, R. M., & Soriano, R. P. (2021). Bates' guide to physical examination and history taking (13th ed.). Wolters Kluwer.
Lieberthal, A. S., Carroll, A. E., Chonmaitree, T., Ganiats, T. G., Hoberman, A., Jackson, M. A., Joffe, M. D., Miller, D. T., Rosenfeld, R. M., Sevilla, X. D., Schwartz, R. H., Thomas, P. A., & Tunkel, D. E. (2013). The diagnosis and management of acute otitis media. Pediatrics, 131(3), e964-e999. https://doi.org/10.1542/peds.2012-3488
Zubler, J. M., Wiggins, L. D., Macias, M. M., Whitaker, T. M., Shaw, J. S., Squires, J. K., Pajek, J. A., Wolf, R. B., Slaughter, K. S., Broughton, A. S., Gerndt, K. L., Mlodoch, B. J., & Lipkin, P. H. (2022). Evidence-informed milestones for developmental surveillance tools. Pediatrics, 149(3), Article e2021052138. https://doi.org/10.1542/peds.2021-052138
NURS 3025 Week 9 instructions, in plain terms
The ninth NURS 3025 week commonly asks for a focused note on a patient from a special population, such as a child or older adult. You adapt the history and examination to the population, name the historian when someone else reports, document focused findings in standard terms and keep the plan within your scope. Faculty score adaptation, looking for changes made to fit the patient. Cite the course text and relevant guidance in APA 7. The same structure works for an older adult with different adaptations. The plan may be limited because diagnosis and prescribing belong to the provider. Keep the child composite or remove every identifier. NURS 3025 faculty want the historian named with how she knows, and the history adapted to cover fever, intake, daycare exposure and immunizations.
How this NURS 3025 Week 9 example is built
Two and a half pages in SOAP order. The subjective section names the parent as historian and records the onset of ear pain, fever as measured at home and by what method, sleep and feeding changes, and immunization status as the parent reports it, each attributed. The objective section gives weight, height and temperature with units, and percentile placement for the growth measures, then an ear examination documenting each ear separately: external ear, canal, and tympanic membrane by color, position and visible landmarks. Throat and cervical lymph nodes follow as related regions. A line notes the child's cooperation and the positioning used, since both affect what could be seen. The assessment ties findings to nursing concerns such as comfort and hydration, and the plan lists the teaching documented for the caregiver, with no prescribing content anywhere.
NURS 3025 Week 9 rubric: what earns full marks
Focused notes on special populations are usually scored for adaptation, and graders look for evidence that the author changed the documentation to fit the patient rather than pasting an adult template onto a child. Naming the caregiver as historian is the first place that shows. Growth data without percentiles loses points in most pediatric versions of this prompt, as does a developmental context left out entirely. Focus is marked as well: a note that runs the full review of systems at equal depth has missed what 'focused' asks for, while one that documents only the ear omits the related regions a grader expects. The SOAP boundaries are checked, and assessment language appearing in the objective section is a standard deduction. Plans that stray into prescribing content are marked as outside scope.
NURS 3025 Week 9 help: mistakes that cost marks
Special population notes lose credit when they look like an adult note with the age changed. Show the adaptations, such as a parent historian and weight for dosing. Another common gap is skipping the historian's reliability. Name who reported and how they know. Writers also describe the eardrum as red only. Describe color, position, light reflex and mobility if tested. Avoid prescribing in a nursing note. Keep the plan to comfort, education and referral. Record immunizations and daycare exposure. Close with return precautions the mother can use. Writers also forget the child's own behavior during the exam, which belongs in the objective data. Describe it.
Get a NURS 3025 Week 9 example written to your instructions
Tell the desk which population your Week 9 prompt names, whether a child, an older adult or a pregnant patient, and attach the rubric and any case details. The focused note returns adapted to that population in SOAP order or your section's template. The first sample costs nothing, and delivery takes 24-48 hours.
More NURS 3025 papers and BSN samples
- NURS 3025 Week 1: Documentation Exercise
- NURS 3025 Week 2: Health History
- NURS 3025 Week 3: Findings Language Post
- NURS 3025 Week 4: Integumentary Write-Up
- NURS 3025 Week 5: Cardiopulmonary Documentation
- NURS 3025 Week 6: Abnormal Findings Post
- NURS 3025 Week 7: Abdominal and MSK Write-Up
- NURS 3025 Week 8: Neurological Assessment Note
- NURS 3025 Week 10: Head-to-Toe Write-Up
- NURS 3025 Week 11: Documentation Reflection
- NURS 3030 Week 9: Stakeholder and Policy Revision
- NURS 3021 Week 9: Sustaining Change Reflection
- NURS 3111 Week 9: Chart Access Ethics Post
- NURS 4300 Week 9: Project Manuscript
NURS 3025 Week 9 questions, answered
My prompt names an older adult, not a child. Does this example still help?
The adaptation logic transfers and the details do not. An older adult note shifts different elements, such as functional status, medication review and cognitive screening, and that version is built to your prompt rather than bending the pediatric one. What carries over is the principle graders reward: documentation visibly changed by the population, not a standard adult template with a new age at the top.
Why is the plan so limited?
Because the course grades assessment and nursing documentation, and a plan that orders medications or tests steps outside that role. The example's plan records the teaching given to the caregiver and when the findings would be documented again. The same limit keeps the page itself free of anything resembling care instructions for a real child.
Can I base the note on a child from my clinical setting?
Not in a sample. Children's records carry privacy protections on top of the usual ones, and the example's four-year-old exists only on the page, assembled from typical presentations. Your own program's rules decide what a class submission may draw from practice. What the sample offers is the documentation pattern, applied to a case that belongs to nobody.
Where can I find a free NURS 3025 Week 9 sample paper?
The 4-year-old's ear pain note is on this page with the parent historian named, the adapted history, the otoscopic findings and a plan within nursing scope.
Who gives the history in NURS 3025 Week 9?
The 4-year-old's mother, named as historian with her reliability noted first.