SAINT PAUL UNIVERSITY DUMAGUETE

COLLEGE OF NURSING

SOAPIE FORM
Patient’s Name (Initial): Admitting Impression/Medical Diagnosis/CC:
Age: Sex: Physician (Initials):
Room No: Diet:
Date and time of Admission:

ASSESSMENT Implementation:
Subjective::

Objective:

Analysis:

Evaluation:

Planning

Name of Student Nurse: SN-SPUD

Proposed By: Mrs. Sharry Mae G. Awayan, RN, MAN

 SAINT PAUL UNIVERSITY DUMAGUETE
COLLEGE OF NURSING

IN PARTIAL FULFILLMENT OF THE REQUIREMENT IN

NCM 107 (RELATED LEARNING EXPERIENCE)

SUBMITTED TO:

SUBMITTED BY:

DATE:
 SAINT PAUL UNIVERSITY DUMAGUETE
COLLEGE OF NURSING

NURSING CARE PLAN FORM

Patient’s Name (Initials): Admitting Diagnosis/Medical Diagnosis/CC:

Age: Sex: Physician (Initials):
Room No: Diet:

SUBJECTIVE OBJECTIVE NURSING DIAGNOSIS SCIENTIFIC ANALYSIS PLANNING INTERVENTIONS RATIONALE EXPECTED OUTCOME
Patient verbalized, “Ga  Audible Ineffective airway Presence of secretions After 8 hours of nursing INDEPENDENT: INDEPENDENT: Pt. will show normal
hu-ot ako dughan sir ug wheezing in the bronchi will result care, the patient will 1. Establish rapport. 1. To gain pt.’s trust. breathing and ventilation
clearance R/T
kutas kayo”  SOB manifest signs of 2. Monitor and Record VS. 2. Track changes or pattern:
 Coughing with
increased production into a blockage of air decreased respiratory 3. Monitor breath sounds improvements.  Normal RR
of secretions as that will enter the body effort as evidenced by and airway pattern. 3. Track changes or
secretions  Clear breath
 Pallor
and thus producing absence of dyspnea and 4. Elevate head of the bed improvements. sounds w/o
evidenced by
 Diaphoresis insufficient air needed coughing w/ secretions. and change position every 4. Minimize difficulty in secretions
productive cough and The patient will verbalize two hours. breathing.
 Cold, clammy by the body. And  Absence of cough
dyspnea inability to maintain understanding of causative 5. Encourage deep 5. Maximize effort of  Relaxed
skin
 Nasal Flaring factors and actions that breathing and coughing expectoration. accessory
clear airway. This
would improve breathing exercises. 6. Prevent Fatigue. muscles
 Neck vein obstruction is further pattern. 6. Encourage fluid intake 7. Prevent situations that  Non anxious
distension Definition: heightened by (6-8 glasses of water or 3 aggravate condition. Pt will understand
 Hypertrophic It is considered the bronchospasm due to liters) 8. Temperature, humidity treatment.
neck muscles state in which the the contraction of the 7. Encourage patient to and number of people
 Anxious EVALUATION
rate, depth, timing, smooth muscles in the restrict activities and rest affect stress and
 Tired facial After 8 hours of nursing
and rhythm, or the bronchi. This is caused as much as possible. exhaustion.
expression interventions, the patient
pattern 8. Provide environment 9. Education provides
by parasympathetic was able to demonstrate
of breathing is conducive to relieve motivation to increase
Vital Signs: stimulation of the decrease sings of
altered due to fatigue (Limit visitors). activity level and healing.
T: 37.8 muscarinic 2receptors respiratory distress:
9. Plan and schedule of 10. Prevent excessive
P: 100 bpm presence of  RR: 21 cpm.
as well as by chemical activities with patient. fatigue.
RR: 28 cpm increased mucus 10. Alternate activity with 11. Anxiety may result  Clear breath
BP: 130/80 mmhg secretions. mediators released in sounds
response to the rest period. from struggle of not being
11. Assess level of able to breathe properly.  Absence of cough
presence of allergen. anxiety. w/ absence of
12. Changes in the
12. Assess respiratory respiratory rate and secretions
 Relaxed
rate, depth, and rhythm may indicate an accessory
rhythm. early sign of impending muscles
13. Assess for color respiratory distress.  Calm appearance
changes in the buccal 13. Cyanosis indicates  Normal
mucosa, lips, low oxygenation and Integumentary
and nail beds. that breathing is findings

Proposed By: Mrs. Sharry Mae G. Awayan, RN, MAN

 14. Assess ineffective to maintain
Reference: the effectiveness of adequate tissue
cough. oxygenation.
14. Coughing is
15. Assess the amount,
a natural way to clear
color, odor and viscosity
the throat and
of the secretions.
breathing passage of
16. Monitor and
foreign particles,
record intake and
irritants, and mucus.
output (I&O)
15. Normal secretion is
adequately.
clear or gray and
17. Monitor oxygen
minimal, abnormal
saturation using pulse
Reference: sputum is green, yellow,
oximetry.
DEPENDENT: or bloody, malodorous,
1. Ventolin (Salbutamol often copious. Thick
inhaler, 2 inhalations tenacious secretions
every 8 hours) as increase airway
ordered. resistance.
2. Codeine (oral: 15- 16. Provides
30mg, 3 times a day) information on the fluid
3. O2 therapy (2 liters balance of the patient.
per minuet) as ordered. 17. Oxygen saturation
4. IV therapy (PNSS of less than 90%
500cc x 10cc/hr) as indicates problems with
ordered. oxygenation.
5. Reinforce low salt, low DEPENDENT:
fat diet as ordered. 1. treat wheezing and SOB
or bronchospasm.
2. Codeine is an
antitussive to relieve
cough.
3. Supplemental oxygen
for the lungs to be
delivered to the blood.
4. Electrolyte
replenishment helps the pt.
from fatigue.
5. To minimize secretions.

Proposed By: Mrs. Sharry Mae G. Awayan, RN, MAN