Nursing SOAPIE - Discharge Summary

A case of (patient's name) from (address), admitted last (date of admission), for labor pains.
S> "Mo-uli na mi karon," as verbalized by the patient.
O> Seen on bed awake, conscious, coherent, responsive
> Temp 36.4C, PR 74bpm, RR 20cpm, BP 110/80mmHg
> Anxious to go home
> scanty lochia rubra
> fundus, 2 finger's breadth below the umbilicus
> mgh order (date)
A> Effective therapeutic regimen related to positive response to medical and nursing
management.
P> After 1 hr of nursing intervention, the patient will be able to identify means to promote
recovery.
I> Encouraged patient strict compliance to medications.
> Encouraged ambulation.
> Advised to have a regular check-up or visit at her local barangay health center.
> Advised to eat nutritious foods rich in iron, calcium, and protein.
> Remind patient to report to a nearest health clinic if the following would occur: fever, profuse
bleeding, and foul smelling discharges.
> Taught proper breastfeeding, taking a bath , and immunization schedules of the baby.
> Advised to seek guidance from God.
E> Going home, still in.

Nursing SOAPIE - Fever

S> "Gihilantan gihapon siya (He still has a fever)," as verbalized by the SO.
O> Received patient with newly hooked IVF D5 0.3% NaCL 1 liter regulated at 60cc/hr
> Temp 40.3C, PR 128bpm, RR 52cpm
> Hot, flushed skin noted
A> Hyperthermia related to inflammatory process secondary to croup.
P> After 30 minutes of nursing intervention, the patients's body temperature will be reduced to
at least 39C.
I> Assessed vital signs.
> Removed excess clothing and covers.
> TSB done.
> Encouraged increase fluid intake.
> Given 0.5ml of Paracetamol 125mg/5ml syr.
E> Temp 38.6C at 11am.

Nursing SOAPIE - Cough, child

S> "Gi-ubo lagi siya, maglisod na nuon ug ginhawa ( he has cough which makes it difficult for him to breathe well)", as verbalized by the S.O.
O> Received patient with D5LR 1L @ 400cc level, regulated @ 25cc/hr
> Temp 37C, PR 130bpm, RR 45cpm
> Cough noted, productive
A> Ineffective airway clearance: productive cough related to tracheobronchial infection
secondary to pneumonia.
Note: the secondary factor, that is pneumonia, came from the doctor's diagnosis, as
extracted from the patient's record.
P> After 1 hr of nursing intervention, the patient will be able to effectively cough out secretions.
I> Assessed respiration, noted quality, rate, pattern, depth, and use of accessory muscles.
> Assessed changes in vital signs.
> Assessed effectiveness to cough out.
> Noted presence of sputum.
> Given Salbutamol syr, 3ml as ordered
E> "Arang-arang na iyang ginhawa (he can breath better now)", as verbalized by the patient's
mother.

Nursing Student's SOAPIE - Sleep disturbance, noise, 2 days post delivery

S> "Dili ko katulog ug tarong sa gabii, saba man gud ( can't sleep well at night because of the
noise)," as verbalized by the patient.
O> Patient seen lying on bed awake, coherent, responsive
> Temp 37C, PR 80bpm, RR 24cpm, BP 100/70mmHg
> Puffy eyelids
> listless
> Dark circles under eyes
> Yawns frequently
> Lochia Rubra - mild
> Uterine fundus - 2 finger's breath above the umbilicus
A> Sleep pattern disturbance related to noisy environment.
P> After 3 to 4 hrs of nursing intervention, the patient will be able to improve sleep pattern.
I> Established rapport.
> Listened to patient's concerns.
> Identified contributing factors to insomnia.
> Noted environmental factors affecting sleep.
> Recommended limiting intake of chocolate and caffeine before bedtime.
> Provided calm environment.
E> Patient seen taking a nap.

Nursing Student's SOAPIE - Anxiety, separation from baby

S> "magsige gihapon ko ug hunahuna naunsa na akong bata sa nursery (I still keep on thinking
about my baby in the nursery)," as verbalized by the
patient.
O> Patient seen lying on bed, awake, coherent
> Anxious about baby's condition
> Temp 37C, PR 82bpm, RR 24 cpm, BP 100/70 mmHg
> Lochia rubra - scanty
> Uterine fundus 2 fingers' breadth below the umbilicus
A> Mild anxiety related to temporary separation from infant.
P> After 1 hr of nursing intervention, the patient will be able to describe a reduction of the
level of anxiety experienced.
I> Established rapport.
> Observed behavior towards separation from the baby.
> Encouraged to express one's feelings.
> Clarified meaning of her feelings.
> Provided information about the separation of her infant.
> Assisted in going to the NICU.
> Reminded patient the right time for breastfeeding / to go to NICU.
> Provided a calm environment.
> Encouraged diversional activities such as reading the newspaper.
E> "Relax, relax na ko karon (I'm a bit relaxed now)", as verballized by the patient.