SOAPIE

Subjective Objective Assessment Planning Implementation Evaluation

Severe vomiting, fever and Body Temperature: 38.5°C Risk for infection related to The client will display relax Communicate with the The goal is achieved and
right iliac pain acute pain resulting from behavior and talk about his client using therapeutic the client rates the face
WBC Count 25,000/mm increased WBC count experienced regarding the treatment by letting pain level scale of 2 out of
“Aray ! masakit ang aking >4,500—11,000/mm and pain after the 8 hours of himself express his 10 and shows a relax mood
tyan. Tulungan niyo po increased body temp. intervention. emotions due to acute while lying in bed.
ako.” Verbalized by the >36.6 °C. pain.
patient. While in stooped Decrease count of WBC
position and crying loudly. At the end of 8 hours of The client will evaluate the From 25,000/mm to
shift, patient will describe pain using face pain scale (0- 10,000/mm and the body
Intense pain at Mc satisfactory pain control at 10). temp. of the client
Burney’s point. a level less than 3 on a decrease from 38.5 °C to
rating scale of 0 to 10 using 36.6 °C. shows that the
a face scale. infection are already
alleviated.
Symptoms of infection will
decrease such as lowering Administer pain medication
count of WBC From as per doctor’s order.
25,000/mm to 10,000/mm
and the body temp. of the
client will decrease from
38.5 °C to 36.6 °C.
 NURSING SERVICE DEPARTMENT
NURSE’S NOTE- (SOAPIE)
Last Name: First Name: Date Admitted: Room No. Bed No. Hosp. No.
Gen Robert 5/4/19 406 04 18975
Attending Physician: Age: Sex: Civil
Dr. Hernandez, R. Romulo 10 years old Male Status:
Single
DATE/TIME SO NEEDS & PROBLEM: Nursing Intervention Evaluation & to
Problem or Actual Endorse
5/4/19 Subjective Data: Risk for infection as The client will evaluate the pain using face pain scale The goal was met and the
- Severe vomiting, fever evidence by an increased in (0-10). Help the client to relax by encouraging to state patient states that the pain
6:30 am and right iliac pain
WBC count his feelings regarding the pain. level is at rating scale of 2
- Crying loudly using a face scale and
- “Aray ! masakit ang >4,500—11,000/mm,
Discharge aspirations from vomiting will be further shows a relax mood while
aking tyan. Tulungan increased body temp.
niyo po ako.” examine by the laboratory and the amount will be lying in bed.
>36.6 °C. and right iliac noted. Refer to the physician for consultation.
Verbalized by the
pain at Mc burney’s point The client displays relax
patient.
- Intense pain at Mc Administer pain medication as per doctor’s order. behavior and talk about
Burney’s point. “Aray ! masakit ang what he experienced
aking tyan. Tulungan Assist patient during activities such as helping regarding the pain after 8
Objective Data: positioning in bed and avoiding the location of affected hours.
- PR-70 bpm niyo po ako.” Verbalized
area and monitor vital signs every 1 hour.
- RR- 25 bpm by the patient while
- Body Temperature: crying loudly.
38.5°C
Decrease count of WBC
- elevated WBC Count From 25,000/mm to
25,000/mm 10,000/mm and the body
temp. of the client
decrease from 38.5 °C to
36.6 °C. shows that the
infection are already
alleviated.