University:
West Coast University
Course:
NURS 110 | Introduction to Professional Nursing
Academic year:

2023
Views:

84

Pages:

2
Author:

ilikemyicons0y5

1 NURS 223 Case Study/SOAPIE Note Problem-Oriented Charting The common charting format SOAPIE is ideal for a narrative client record of the nursing process. SOAPIE, a systematic approach, details a goal-oriented nursing care plan in a note. SOAPIE Note S Subjective (report what the client states) O Objective (record what the nurse observes (also measurable – vital signs, physical assessment, laboratory tests) A Assessment (analysis, generate the nursing diagnoses) P Plan (outcomes; actions to be taken) I Implementation (records how those actions were carried out) E Evaluation (reports the actual client outcome or response) Case Study (Learning Outcome # 7) David, an 80-year-old man, is admitted to the hospital with a diagnosis of possible pneumonia. He states that he is not feeling well and has a frequent productive cough, which is worse at night. Vital signs are: blood pressure 150/90 mm/Hg; pulse rate 92 beats/min; respirations 22 breaths/min; pulse oximetry 90%. His lungs have wheezing and rhonchi in both bases and are otherwise clear. He states, “My chest hurts when I cough, and the pain radiates into my arms.” 2 Use SOAPIE to write a narrative note based on the case study (use your Nursing Dx Reference Manual – NANDA text as needed) S (subjective data): “My chest hurts” he isn’t feeling well. Cough gets worse at night and pain radiates into his arm O (objective data): Vital signs, frequent productive cough, his age A (assessment- diagnosis based on the data): Ineffective airway clearance related to productive cough as evidenced by Impaired gas exchanged related to retained secretions as evidenced by pulse and RR rate results Acute pain as evidenced by coughing P (write one outcome; what the nurse plans to do): Client will have a clear airway, will communicate a decreased pain level, RR between 12-20, pulse will return to normal rage. Change position and elevate the head of the bed. Get them a prescription of an incentive spirometer Evaluation: