SOAPIE,

Assessment
and NCP

Submitted to:
Ms. Kristy Nillet Pongos R.N.

Submitted by:
Busa, Ana Marie
Nodalo, Evelyn
 BSN II-C

SOAPIE

S Magsinakit gihapon ako tiil labina kung molihok, as

verbalized by the patient.

O Seen patient lying on bed, without IV, conscious, coherent,

grimaced face, swollen left leg, guarding behavior near the affected
part. Pain usually occurs almost everyday located at the left leg with
a duration of 1-3 minutes, characterized by a gnawing pain
aggravated by excessive movements and during standing, relieved
by immobilizing the affected area and deep breathing exercises,
treated by analgesics as ordered by physician, pain scale of 5.

A Alteration in comfort, pain related to tissue trauma secondary

to fracture

P To alleviate pain
I Approached patient in a pleasant manner, Encouraged patient to

verbalize feelings about pain, Accepted clients description of pain,

Instructed patient to immobilize the affected area, Taught deep
breathing exercises, Provided diversional activities like socialization,
Assisted patient in proper positioning, Encouraged to avoid exercise
movements, Encouraged to have bedrest, Vital signs taken and
charted.

E The patient was able to verbalize relief of pain felt from pain

scale of 5 to 3.
 ASSESSMENT

Physiologic
Inspection Palpation Percussion Auscultation
Body Part
Extraocular
movements, intact
Muscle Function
bilaterally, both
eyes is coordinated
Patient was able to
see examiners
Peripheral Vision
finger without
moving his head
Located at the No pain felt during
Nose
midline of the face palpation
Red Glow observed
No pain felt during
Frontal Sinuses during transluminal
palpation
illumination
Red Glow observed
No pain felt during
Maxillary Sinuses during transluminal
palpation
illumination
Mouth
Lips Dry lips and pale
No discoloration,
Gums bleeding & swelling
observed.
Tongue Presence of saliva.
 A thin white
costing is noted.
Pale-pink in color,
Sublingual area moist and absence
of lesions.
Ears
Both ears are
brown in color,
symmetrical.
External Firm. No pain felt.
Absence of lesions.
No discharges are
observed.
No discharges are
Internal
observed.
The patient can
Auditory Acuity hear well at 3-5ft.
from the bed
Carotid Pulse is
Brown in color.
Neck present with 95
Absence of scars
bpm.
No enlargement is
Lymph Nodes
observed
Trachea is in
Located in the midline and doesnt
Trachea
midline move when it is
palpated
Thorax
Brown in color, no
Vibration felt.
rashes and lesions. No adventitious sound
Chest anterior RR=24 Resonance heard
Contour is heard
breaths/min.
symmetrical.
Posterior thorax Brown in color, no Vibration felt Resonance heard No adventitious sound
rashes and lesions. heard
 Contour is
symmetrical.
Heart Dull sound heard HR=100 bpm
Brown in color.
Absence of rashes.
The umbilicus is in
Tympany sound is Burborygmus sound is
Abdomen the midline. Pain felt
noted heard.
Guarded by his
hands when pain
occurs.
Presence of Scars.
Brachial and Radial
No rashes and
pulse present with Biceps and triceps
Upper Extremeties lesions. Both arms BP: 100/70
90bpm. Auxiliary reflex present
are weak. Guarding
temp: 36.8C
the abdomen.
Absence of scars Popliteal and
Knee jerk reflex ,
and legs are weak. dorsalis pedis pulse
Lower Extremeties Achilles reflex are
Dizziness during are present with
present.
sudden movement. 85pm.
 San Lorenzo Ruiz College
Ormoc City
Nursing Care Plan

Name of Patient: Busa, Ana Marie Date:

October 18, 2009
Room #: 1
Problem/Needs Nursing Scientific Objective of Nursing Rationale
Cues Diagnosis Basis Care Action
Subjective: Alteration in The patient After 8 hrs of 1. Encourage 1. To assist
Comfort: with acute holistic nursing verbalization patient to
Magsinakit jud ako Acute Pain gastritis may care, the of feelings explore
tiyan, as verbalized related to have patient will be about pain. methods of
by the patient. disease abdominal able to control of pain.
process discomfort, verbalize 2. Accept
Objective: headache, reduce of pain patients 2. Pain is a
-Guarding on the nausea, from painscale description of subjective
affected part vomiting and of 6 to 3. pain experience and
-grimaced face and hiccupping. In cannot be felt
irritability were gastritis the by others.
observed when pain gastric Acknowledge
occurs. membrane the pain
-The part is located at becomes experience and
the epigastric region edematous convey
of the abdomen with and hyperemic 3. Position acceptance of
the duration of 1-2 and undergoes patient to the clients
mins. superficial unaffected response to
-It is characterized by erosion. It area. pain.
crushing pain and secretes a
aggravated by scanty amount 4. Provide 3. To allocate
frequent movements. of gastric acid, comfort pain
-It is relieved by deep containing measures
breathing exercises very little acid. (back rub,
and diversational Superficial change of 4. To promote
activities. viceration may position). nonpharmacolo
-It is treated by occur and can gical pain
analgesics as lead to 5. Instruct management.
prescribed by the hemorrhage. the patient to
physician. Pain scale do deep 5. To distract
of 6. Source: breathing attention and
Medical exercises. reduce tension.
Surgical
Nursing 6. Encourage
by: Lemon & diversational 6. To distract
Burke p1011 activities (e.g. attention and
socialization). reduce tension.
7. Administer
analgesic/anti 7. To maintain
ulcer as acceptable
ordered. level of pain.
Source: Source:
Nursing Pocket Nursing Pocket
Guide by: Guide by:
Doenges 11th Doenges 11th
Edition p 500- Edition p 500-
502 502