Sunday, November 30, 2008

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.

1 comment:

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