9 Tips on How To Make a Good SOAPIE

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Sample SOAPIE

And lastly, here is an example SOAPIE, with all the things you have learned above can you comment what’s wrong with this SOAPIE?

• S > (none) O> Received pt sitting in bed conscious and coherent, with IVF of #7 D5W 1L infusing well on the right metacarpal vein regulated 30 gtts/min at 300 cc level, without signs of phlebitis or infiltrations. O2 inhalation therapy via NC regulated @ 2LPM pt appears fatigued and weak, pt is acyanotic, without pallor, without edema, with pink conjunctiva, moist mucous membranes, capillary refill less than 3 seconds, poor skin turgor, pt has cough with lung fields clear upon auscultation, with chest pain provoked with activity, pt’s heart rate is irregular and bradycardic, with ecchymosis on L forearm, vital signs taken as follows: BP 90/50 48 22cpm 36.7
• A > Decreased cardiac output R/T altered heart rate
• P> After 4-5 hours of NI the patient will be able to identify health interventions that will decrease cardiac workload of the heart
• I >
  • Established rapport
  • Monitored and recorded VS q1
  • Provided AM care
  • Positioned pt in fowler’s bed rest to allow easy respiratory function
  • Reinforced low sodium and low fat diet
  • Instructed pt to limit oral fluid intake
  • Arranged and straightened linens
  • Provided privacy, comfort and safety measures
  • Provided adequate rest periods
  • Assisted pt’s SO with pt’s ADLs
  • Instructed pt to avoid strenuous activities that may stimulate Valsava maneuver
  • Due available meds given as ordered
  • Seen on rounds by Dr. N with orders given and carried out as follows:
    • Atrophine sulfate ½ amp administered SIVP

E> Goal met AEB pt was able to identify health interventions that would allow decrease in cardiac work load.

Navigation

1. Assess
2. Know what your doing
3. NANDA out!
4. Stop Using Acute Pain…
5. …Choose a better nursing diagnosis!
6. Planning should be SMART and PtC
7. Interventions
8. Horray! Evaluation
9. And to Top it all up…
10. Sample SOAPIE