Saturday, August 21, 2010

Tips on Making a SOAPIE

SOAPIE charting is:
S (subjective data) - chief complaint or other information the patient or family members tell you.
O (objective data) - factual, measurable data, such as observable signs and symptoms, vital signs, or test values.
A (assessment data) - conclusions based on subjective and objective data and formulated as patient problems or nursing diagnoses.
P (plan) - strategy for relieving the patient's problems, including short- and long-term actions.
I (interventions) - measures you've taken to achieve expected outcomes.
E (evaluation) - analysis of the effectiveness of your interventions.
R (revision) - changes from the original care plan"

1. Nursing Diagnosis: Nausea related to anesthetic
S: Patient states, "I feel nauseated."
O: Patient vomited 100mL of clear fluid at 2255.
A: Patient is nauseated.
P: Monitor nausea and give antiemetic as necessary.
I: Patient given Compazine 1mg IV at 2300.
E: Patient states she's no longer nauseated at 2335.

2. Nursing Diagnosis: Risk for infection related to incision sites
[notice there is no "S" charted--no subjective data to chart]
O: Incision site in front of left ear extending down and around the ear and into neck--approximately 6" in length--without dressing. No swelling or bleeding, bluish discoloration below left ear noted, sutures intact. Jackson-Pratt [JP] drain in left neck below ear with 20mL bloody drainage. Drain remains secured in place with suture.
A: No infection at present.
P: Monitor incision sites for redness, drainage, and swelling. Monitor JP drain output. Teach patient S&S [signs and symptoms] of infection prior to discharge. Monitor temperature

3. Nursing Diagnosis: Delayed surgical recovery
O: Patient oriented x 3 but groggy. Patient attempted to get OOB [out of bed] at 2245 to ambulate to bathroom but felt dizzy upon standing. Lungs sound clear bilaterally.
A: Patient is dizzy when getting OOB. Patient needs post-op education about mobility and coughing and deep-breathing exercises.
P: Allowed patient to use bedpan. Assist in getting OOB in 1 hour by dangling legs on side of bed for a few minutes before attempting to stand. Monitor blood pressure. Teach patient how to get out of bed slowly to prevent dizziness and to ask for assistance. Teach coughing and deep breathing, turning, use of antiembolism stockings.
I: Allowed patient to lie down in bed after feeling dizzy. Patient used bedpan and voided 200mL clear, yellow urine at 2245. Assisted in coughing and deep-breathing exercises and taught about turning, use of antiembolism stockings.
E: Lungs remain clear bilaterally.