example nursing soapie

Name: Booc, Tiffany Rose
Age: 2 years old
Gender: F
Nationality: Filipino
Religion: Iglesia ni Cristo
AP: Dr.De Castro
Dx:AGE with DHN
Diet:SFF

CUES
ASSESSMENT
PLANNING
IMPLEMENTATION
EVALUATION Received lying on bed hooked to #3 D5IMB at a rate of 15 – 16 gtts/min, received at 100cc level infusing well

“masakit ang tyan nya”

T : 36.4c
BP: 90/60mmhg
HR: 114bpm
RR: 43cpm
Acute pain secondary to Abdominal cramps
The patient will show relief after a satisfactory relief measure as evidence by facial expression from grimace to calmed.
Assessed VS q4 and recorded

Changed IV fluid

Assessed I&O and recorded

Promote relaxation with massage.

Teach mother specific relaxation strategy
GOAL MET

Name: Pareño, Rudylyn
Age: 7 years old
Gender: F
Nationality: Filipino
Religion: Catholic
AP: Dr. Casubha
Dx: Amoebiasis with moderate dehydration
Diet: SFF

CUES
ASSESSMENT
PLANNING
IMPLEMENTATION
EVALUATION Received lying on bed hooked to #7 D5LM 1L at a rate of 19 – 20 gtts/min, received at 450cc level infusing well

“nagsusuka at masakit ang tyan nya”

T : 35.5c
BP:
HR:88bpm
RR: 20cpm
Nausea related to amoebiasis with moderate Dehydration
The patient will scale a decrease in pain from 5-1 from being 1 the lowest and 10 being the most painful
Assessed VS q4 and recorded

Changed IV fluid

Assessed I&O and recorded

Diversionary measures by giving activities such as coloring book and crayons
GOAL MET

Name: Gavarra Brian
Age: 2 years old
Gender: M
Nationality: Filipino
Religion: Catholic
AP: DR. Magno
Dx: AGE with DHN
Diet: DAT and SAP

CUES
ASSESSMENT
PLANNING
IMPLEMENTATION
EVALUATION Received lying on bed

MGH

“wala naming masakit”

T : 36.2c
BP:
HR:120bpm
RR: 26cpm
Readiness for enhanced Comfort
With in the shift patient will be able to express desire to enhance relaxation.